Cerebellar hemorrhage as a complication of spine surgery.

BACKGROUND: The association between remote cerebellar hematoma (RCH) and spinal surgery is poorly understood and rarely reported. We present seven cases of RCH after spinal surgery.
METHODS: Seven patients were diagnosed with RCH utilizing computed tomography and/or magnetic resonance, between 2012 and 2016. Their clinical presentations, imaging data, treatment modalities, and outcome were analyzed. There were five females and two males with an average age of 55.8 ± 8.4 years. The age of onset ranged from 43 to 67 years and the time to clinical presentation ranged from 3 h to 5 days. Patients presented with: diplopia/strabismus (one patient), dysphagia/urinary incontinence (one patient), respiratory arrest (one patient), meningismus (one patient), and dysarthria (two patients), along with other symptoms/signs.
RESULTS: Three patients were successfully managed without surgery, two required external ventricular drainage, and two were treated with posterior fossa decompression plus ventriculostomy. Four patients recovered completely, two showed mild residual deficits at discharge, while one expired 7 days postoperatively.
CONCLUSION: RCH is an uncommon and underdiagnosed complication of spine surgery. It should be suspected when intracranial symptoms occur after spinal procedures.

INTRODUCTION

“Remote cerebellar hemorrhage” (RCH) is a rare complication of spinal surgery and may have catastrophic consequences. Cevik et al. reported an incidence of 0.08% among 2444 lumbar surgeries.[2] The most likely etiology is an intraoperative cerebrospinal fluid (CSF) leak resulting in excessive intraoperative CSF drainage I, downward cerebellar traction, and stretching/occlusion of the cerebellar veins resulting in hemorrhagic venous infarction.[4,6,11]

Here, we present seven cases of RCH after spine surgery that included an intraoperative dural fistula.

METHODS

Patient population

We retrospectively reviewed the clinical presentation, operative notes, imaging data, treatment modalities, and outcomes of seven patients with intraoperative CSF fistulas resulting in RCH following spinal surgery (2012–2016).

Literature review

We reviewed the literature regarding RCH after spinal surgery that included a CSF fistula; 65 articles involving 70 patients were analyzed, to which we now add seven cases [Table 1].

Table 1:

Patients status after spine surgery who were found to have a remote cerebellar hemorrhage.

RESULTS

The clinical presentations, operations, operative findings, and outcomes for these seven patients are summarized in Table 2.

Table 2:

Summary of literature about Cerebellar Hemorrhage after spine surgery.

DISCUSSION

RCH is an infrequent complication of spine surgery. RCH more likely occur in patients with intraoperative CSF fistulas (93%) draining large volumes of CSF.[4,5,8,11]

Chadduck[3] described the RCH syndrome following the performance of a cervical laminectomy with durotomy performed in the sitting position. Other cases involve surgery and dural fistulas at all spinal levels. Sturiale et al.[9] suggested that the more common involvement of the lumbar spine is due to the higher rates of degenerative diseases in the segment. Moreover, the use of pedicle screws may increase the risk of occult fistulas.[9] In our series, six operations involved the lumbar spine while one patient had thoracic surgery.

Etiology of RCH

The majority of the RCH is attributed to venous hemorrhagic infarction,[10] i.e., descent of cerebellum with stretching/occlusion of superior cerebellar veins and temporary occlusion.[1,6,11] The common bilateral cerebellar involvement reinforces the venous theory, as arterial bleeds are typically unilateral.[1]

Time of onset of RCH

About 50% of RCH occur 24 h after surgery.[9] As most patients do not undergo a routine postoperative brain magnetic resonance imaging, the true incidence may be higher.[4,9] In one study (2006),[7] the RCH occurred between 16 and 120 h postoperatively. In our series, the RCH usually presented between the 1st and the 3rd postoperative day (range 3 h–5 days).

Clinical findings for patients who develop RCH

Patients ranged in age from the fourth to the sixth decade. Of these, 72% were women. One paper[9] suggested an average age of 57.6 years of age, and a male/female ratio of 2:3.

Symptoms of RCH

The symptoms of RCH depend on the extent and severity of the RCH. These include uniformly, headache, altered level of consciousness, and cerebellar signs often including dysarthria.[9] In this series of seven patients, all had a headache, 71% had cerebellar signs, 57% had altered level of consciousness, 28% had vomiting, and 14% had meningismus. Mild neurological deficits such as ataxia and neurogenic bladder were present in the other patients.

Outcomes of RCH following CSF fistula during spinal surgery

Outcomes vary due to several factors including extent of bleeding, intracerebellar component, underlying disease, amount of time before action is taken and presence of further complications.[6] The risk of acute obstructive hydrocephalus and brainstem compression is directly related to the size of the hemorrhage and cerebellar ischemia. In our series, four of seven patients recovered (57%), while one expired. These findings are similarly reflected in literature.[9]

Nonsurgical versus surgical management

Small hematomas can be managed conservatively,[9] while large hematomas are causing a mass effect at the posterior fossa often require surgical decompression.[3,9] Most of our patients required surgery, one needed external ventricular drainage, one needed craniectomy plus duroplasty, two required both procedures, and three of them were treated conservatively due to small hematomas and no consciousness deterioration.

CONCLUSION

RCH should be considered in patients who have unexpected neurological deterioration after spinal surgery involving an intraoperative CSF fistula. Early recognition of RCH and confirmation with neuroimaging investigation allows for quick proper management, and better outcomes.