Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Remote cerebellar hemorrhage following thoracic spinal surgery of an intradural extramedullary tumor: a case report

  • Masazumi Suzuki1Email author,
  • Takashi Kobayashi1,
  • Naohisa Miyakoshi2,
  • Eiji Abe1,
  • Toshiki Abe1 and
  • Yoichi Shimada2
Journal of Medical Case Reports20159:68

https://doi.org/10.1186/s13256-015-0541-8

Received: 22 August 2014

Accepted: 3 February 2015

Published: 26 March 2015

Abstract

Introduction

Remote cerebellar hemorrhage is a rare complication of spinal surgery. Although loss of cerebrospinal fluid seems to play an important role in the pathogenesis of this complication, the detailed mechanism of remote cerebellar hemorrhage after spinal surgery remains unclear. We report the case of a patient with remote cerebellar hemorrhage following thoracic spinal surgery of an intradural extramedullary tumor and discuss this entity with reference to the literature.

Case presentation

A 57-year-old Japanese woman presented to our hospital with back pain, dysuria, and numbness of both legs. A neurological examination was performed, and imaging was performed with ordinary radiography, magnetic resonance imaging, and computed tomography. Her magnetic resonance imaging scan showed an intradural extramedullary tumor at the T3 level. A tumor resection and T1-T5 pedicle screw fixation were performed. Twelve hours after spinal surgery, she complained of unexpected dizziness, nausea, and vomiting. A total of 850mL of serosanguineous fluid had been drained at that time, and drainage was stopped. An urgent brain computed tomography scan showed a cerebellar hemorrhage. She was treated conservatively, and was able to leave hospital six weeks after the initial operation, without any neurological deficits except for slight ataxia.

Conclusions

Remote cerebellar hemorrhage has to be suspected when unexpected neurological signs occur after spinal surgery. If an excessive amount of cerebrospinal fluid drains from the drainage tube after spinal surgery, drainage should be stopped.

Keywords

Postoperative complication Intradural extramedullary tumor Remote cerebellar hemorrhage Spinal surgery Thoracic spine Neurological signs

Introduction

Remote cerebellar hemorrhage (RCH) following spinal surgery is a rare complication [1-25]. Although loss of cerebrospinal fluid (CSF) plays an important role in the pathogenesis of this complication [1-25], the detailed mechanism of RCH after spinal surgery remains unclear. Here, we present a case of RCH after thoracic spinal surgery for an intradural extramedullary tumor, along with a review of previously reported cases and a discussion of the mechanism of RCH.

Case presentation

A 57-year-old Japanese woman, with no past medical history, presented to our institution with a one-year history of abdominal pain, a two-month history of back pain, numbness of both her legs, and a one-month history of dysuria. She initially reported abdominal pain and underwent extensive gastroenterological evaluation at another hospital, including an esophagogastroduodenoscopy, which was unremarkable.

Her physical examination revealed no motor weakness and normal tendon reflexes. She felt hypoesthesia below the umbilicus. Magnetic resonance imaging (MRI) results demonstrated a large intradural extramedullary mass at the T3 level that was compressing her spinal cord from the ventral side (Figure 1).
Figure 1

Preoperative magnetic resonance images. Sagittal T1-weighted (a) and T2-weighted (b) magnetic resonance images of the thoracic spine, demonstrating an intradural extramedullary mass anterior to the spinal cord at the T3 level. The mass was iso-intense on T1-weighted imaging and T2-weighted imaging. Axial T1-weighted (c) and T2-weighted (d) magnetic resonance images show that the tumor seemed to be completely covered by the spinal cord.

The intradural extramedullary tumor was resected through a laminectomy of T2-T4 and a facetectomy of T2-T3 and T3-T4 in the prone position under transcranial motor-evoked potential (MEP) monitoring. As the tumor was completely covered by her spinal cord, it was surgically removed by rotation of the spinal cord using tenting of the dentate ligament. After tumor resection, the dura that adhered to the tumor was cauterized. A watertight repair of the dura was performed, using fibrin glue to avoid CSF leakage. A T1-T5 pedicle screw fixation was performed (Figure 2). Abnormal MEP signals were observed on her left leg during and after the tumor resection. A subfascial drain was put in place, with negative pressure. After she woke the motor power was weakened to grade three to four in her left knee and ankle. The total operating time was 4 hours 39 minutes, and the amount of bleeding was 108g. The histological diagnosis of the tumor was a meningioma.
Figure 2

Postoperative radiographs. Postoperative anterior-posterior (a) and lateral (b) radiographs showing T1-T5 pedicle screw instrumentation.

Twelve hours after surgery, she developed nausea and confusion, and her clinical status deteriorated with loss of consciousness (Glasgow Coma Scale score of seven). A total of 850mL serosanguineous fluid had been drained at that time, and drainage was stopped. An emergency brain computed tomography (CT) scan demonstrated an acute cerebellar hemorrhage in the superior folia of the cerebellar hemispheres (Figure 3). An MRI scan demonstrated a herniation of the cerebellar tonsils (Figure 4a, b). She was treated conservatively with anti-edema and antihypertensive drugs, and her clinical status improved gradually. After removal of the drain, there was no CSF leakage. The results of her follow-up CT scan performed one week later showed that her hematoma and brain edema were decreased. Twelve days later, the results of her follow-up MRI scan showed ascent of the cerebellum to the normal position (Figure 4c, d). At six weeks after surgery, she had slight ataxia and was discharged with a cane. At her one-year follow-up assessment, she had a normal neurological examination except for hypoesthesia of the right leg, and there was no CSF collection visible on her MRI scan.
Figure 3

Non-enhanced plain computed tomography scan of the head taken 13 hours after spinal surgery, demonstrating an acute cerebellar hemorrhage in the superior folia of the cerebellar hemispheres (white arrows). (a) At the low cerebellum level, (b) At the cerebral peduncles level.

Figure 4

Sagittal magnetic resonance imaging taken 13 hours and 12 days after spinal surgery. Sagittal T1-weighted (a) and T2-weighted (b) magnetic resonance images taken 13 hours after spinal surgery, demonstrating herniation of the cerebellar tonsils. Sagittal T1-weighted (c) and T2-weighted (d) magnetic resonance images taken 12 days after spinal surgery demonstrating ascent of the cerebellum to the normal position.

Discussion

Our case report has two characteristics. First, this case of thoracic meningioma that was located anterior to the spinal cord presented with a one-year history of undiagnosed abdominal pain. Lyons et al. [26] reported a similar case presenting as chronic abdominal pain. Second, although the tumor (which completely covered the spinal cord) was totally removed with a posterior surgical approach, our patient had some left lower extremity weakness postoperatively that improved gradually. A total resection of intradural extramedullary tumors located anterior to the spinal cord can be performed using an isolated posterior approach, with rotation of the spinal cord and tenting of the dentate ligament [27,28].

RCHs are rare and dramatic complications can follow spinal surgery. Prevention is important, because RCHs sometimes follow a fatal course. Sporadic cases have been published since the first description by Chadduck [4]. At the time of writing, 32 cases of RCH after spinal surgery have been reported in the English-language literature (Table 1). Including the present case, the 33 cases consisted of 23 women and 10 men, with an age range of 36 to 85 years (mean: 60.9 years). Initial surgery was performed at the lumbar spine in 21 cases, thoracic spine in six, cervical spine in five, and thoracolumbar spine in one. A dural tear during surgery was present in 26 cases, but was not noticed in seven cases. The neurological symptoms were detected between 0 and 192 hours (mean: 45.7 hours) after surgery. A total of 16 RCHs were resolved with conservative treatment, but three patients died or developed serious paresis [1-3,5,8,10,11,15,19,21-23]. However, in severe cases, emergency surgical intervention with ventricular drainage or posterior fossa craniotomy was needed. Cranial surgery was performed in 14 patients, nine of whom improved, and five died or had serious paresis after surgery [4,6,7,9,11-14,17,18,20,24,25].
Table 1

Clinical parameters and outcomes in previous reports of remote cerebellar hemorrhage

Author (year)

Surgery

Location

Age, sex

Onset

Dural tear

Treatment

Results

Chadduck (1981) [4]

laminectomy

CS

59, M

2 days

present

surgery

improved

Mikawa et al. (1994) [17]

C1/2 fusion, durotomy

CS

75, M

1 day

present

surgery

died

Andrews and Koci (1995) [1]

scoliosis correction

LS

36, M

36 hours

unknown

conservative

quadriparesis

Friedman et al. (2002) [8]

posterior thoracic disc herniation removal

TS

43, M

12 hours

present

conservative

improved

 

PSF

LS

56, F

2 days

present

conservative

improved

Thomas et al. (2002) [22]

IETR

TLS

38, F

5 days

present

conservative

improved

Farag et al. (2005) [7]

PSF

LS

43, F

36 hours

present

surgery

improved

Karaeminogullari et al. (2005) [12]

PSF

LS

73, F

2 days

present

surgery

improved

Nakazawa et al. (2005) [19]

IETR

CS

74, F

perioperative

present

conservative

improved

Konya et al. (2006) [15]

PSF

LS

48, F

12 hours

present

conservative

improved

Calisaneller et al. (2007) [2]

PSF

LS

67, F

8 days

present

conservative

improved

Cornips et al. (2007) [5]

thoracoscopic microdiscectomy

TS

48, F

3 days

unknown

conservative

died

Hashidate et al. (2008) [9]

vertebral tumor resection

TS

85, F

40 hours

unknown

surgery

improved

Cevik et al. (2009) [3]

laminectomy

LS

79, F

3 days

unknown

conservative

improved

 

PSF

LS

68, F

7 days

unknown

conservative

improved

Enel et al. (2009) [6]

PSF

LS

51, F

30 hours

present

surgery

died

Khong and Jerry Day (2009) [14]

PSF

LS

70, F

36 hours

present

surgery

improved

Morofuji et al. (2009) [18]

laminectomy

TS

51, M

18 hours

present

surgery

improved

Pallud et al. (2009) [20]

laminectomy

LS

73, F

3 days

present

surgery

improved

Ulivieri et al. (2009) [23]

microdiscectomy

LS

53, M

2 hours

present

conservative

improved

Yang et al. (2011) [24]

PSF

LS

56, F

21 hours

unknown

surgery

ataxia and aphasia

Hempelmann and Mater (2012) [10]

IETR

TS

61, F

7 days

present

conservative

improved

 

PSF

LS

69, F

2 days

present

conservative

improved

 

PSF

LS

62, F

1 day

present

conservative

improved

Khalatbari et al. (2012) [13]

discectomy

LS

53, M

8 hours

present

surgery

improved

 

laminectomy

LS

75, M

perioperative

present

surgery

died

Lee et al. (2012) [16]

PSF

LS

63, F

6 hours

present

conservative

improved

Takahashi et al. (2012) [21]

laminoplasty

CS

69, F

15 hours

unknown

conservative

improved

Kaloostian et al. (2013) [11]

PSF

CS

45, M

perioperative

present

conservative

improved

 

PSF

LS

64, F

2 days

present

conservative

brain dead

 

PSF

LS

81, F

1 day

present

surgery

died

Yoo et al. (2013) [25]

intradural disc surgery

LS

66, M

2 days

present

surgery

improved

CS, Cervical spine; F, Female; IETR, Intradural extramedullary tumor resection; LS, Lumbar spine; M, Male; PSF, Posterior spinal fusion; TS, Thoracic spine.

RCH occurs in patients with a dural tear and CSF leakage, whether occult or not. It is thus believed that perioperative and/or postoperative CSF losses, leading to cranial hypotension, represent the main contributing factor in RCH [1,8,12]. The exact pathophysiology of RCH is still controversial. It is suggested that transient stretching and occlusion of superior cerebellar veins, resulting from downward cerebellar displacement under conditions of intracranial hypotension, may lead to cerebellar hemorrhagic infarction [8,20]. It is also suggested that cerebellar sag can directly cause tearing and bleeding of superior cerebellar veins [8]. Pallud et al. [20] hypothesized that RCH results primarily from superior cerebellar venous stretching and tearing, and that cerebellar infarction and swelling occur secondarily.

The loss of CSF should be restricted and controlled, because intracranial hypotension may be the initial cause of RCH. Closed wound suction drainage is recommended for spinal surgery, because a postoperative drain theoretically reduces the risk of infection and/or wound breakdown by decompressing the site of postoperative hematoma formation. However, if too much serosanguineous fluid drains postoperatively, stopping drainage or removing the drainage tube should be considered to prevent intracranial hypotension. Removal of the drain restores the normal CSF flow dynamics, allowing the cerebellum to resume its normal position [1]. Friedman et al. [8] described a 56-year-old woman with postoperative RCH whose headache resolved when suction drainage of the wound was discontinued. Thus, considering our case and the published literature, we suggest stopping drainage when RCH is suspected based on the patient’s complaints, including nausea and headache, and/or if an excessive amount of serosanguineous fluid has been drained postoperatively. This complication can be prevented by observing the amount of drainage fluid. If an excessive amount of fluid is drained, drainage should be stopped or converted to a gravity drain instead of a suction drain.

Conclusions

RCH is a rare postoperative complication of spinal surgery. RCH must be suspected when intracranial symptoms or unexpected neurological signs occur after spinal surgery. If an excessive amount of serosanguineous fluid is found coming from the drainage tube postoperatively, drainage should be stopped.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Abbreviations

CT: 

Computed tomography

CSF: 

Cerebrospinal fluid

CT: 

Computed tomography

MEP: 

Motor-evoked potential

MRI: 

Magnetic resonance imaging

RCH: 

Remote cerebellar hemorrhage

Declarations

Acknowledgments

The authors wish to thank Mamiko Kondo for her valuable assistance with the editing of this manuscript.

Authors’ Affiliations

(1)
Department of Orthopedic Surgery, Akita Kousei Medical Center
(2)
Department of Orthopedic Surgery, Akita University Graduate School of Medicine

References

  1. Andrews RT, Koci TM. Cerebellar herniation and infarction as a complication of an occult postoperative lumbar dural defect. Am J Neuroradiol. 1995;16:1312–5.PubMedGoogle Scholar
  2. Calisaneller T, Yilmaz C, Ozger O, Caner H, Altinors N. Remote cerebellar haemorrhage after spinal surgery. Can J Neurol Sci. 2007;34:483–4.View ArticlePubMedGoogle Scholar
  3. Cevik B, Kirbas I, Cakir B, Akin K, Teksam M. Remote cerebellar hemorrhage after lumbar spinal surgery. Eur J Radiol. 2009;70:7–9.View ArticlePubMedGoogle Scholar
  4. Chadduck WM. Cerebellar hemorrhage complicating cervical laminectomy. Neurosurgery. 1981;9:185–9.View ArticlePubMedGoogle Scholar
  5. Cornips EM, Staals J, Stavast A, Rijkers K, Van Oostenbrugge RJ. Fatal cerebral and cerebellar hemorrhagic infarction after thoracoscopic microdiscectomy: case report. J Neurosurg Spine. 2007;6:276–9.View ArticlePubMedGoogle Scholar
  6. Enel D, Blamoutier A, Bacon P, Gentili ME. Spine surgery associated with fatal cerebellar haemorrhage. Eur J Anaesthesiol. 2009;26:891–2.View ArticlePubMedGoogle Scholar
  7. Farag E, Abdou A, Riad I, Borsellino SR, Schubert A. Cerebellar hemorrhage caused by cerebrospinal fluid leak after spine surgery. Anesth Analg. 2005;100:545–6.View ArticlePubMedGoogle Scholar
  8. Friedman JA, Ecker RD, Piepgras DG, Duke DA. Cerebellar hemorrhage after spinal surgery: report of two cases and literature review. Neurosurgery. 2002;50:1361–3.PubMedGoogle Scholar
  9. Hashidate H, Kamimura M, Nakagawa H, Takahara K, Uchiyama S, Kato H. Cerebellar hemorrhage after spine surgery. J Orthop Sci. 2008;13:150–4.View ArticlePubMedGoogle Scholar
  10. Hempelmann RG, Mater E. Remote intracranial parenchymal haematomas as complications of spinal surgery: presentation of three cases with minor or untypical symptoms. Eur Spine J. 2012;21 Suppl 4:S564–8.View ArticlePubMedGoogle Scholar
  11. Kaloostian PE, Kim JE, Bydon A, Sciubba DM. Intracranial hemorrhage after spine surgery. J Neurosurg Spine. 2013;19:370–80.View ArticlePubMedGoogle Scholar
  12. Karaeminogullari O, Atalay B, Sahin O, Ozalay M, Demirors H, Tuncay C, et al. Remote cerebellar hemorrhage after a spinal surgery complicated by dural tear: case report and literature review. Neurosurgery. 2005;57 Suppl 1:E215.Google Scholar
  13. Khalatbari MR, Khalatbari I, Moharamzad Y. Intracranial hemorrhage following lumbar spine surgery. Eur Spine J. 2012;21:2091–6.View ArticlePubMedPubMed CentralGoogle Scholar
  14. Khong P, Jerry Day M. Spontaneous cerebellar haemorrhage following lumbar fusion. J Clin Neurosci. 2009;16:1673–5.View ArticlePubMedGoogle Scholar
  15. Konya D, Ozgen S, Pamir MN. Cerebellar hemorrhage after spinal surgery: case report and review of the literature. Eur Spine J. 2006;15:95–9.View ArticlePubMedGoogle Scholar
  16. Lee H-Y, Kim S-H, So K-Y. Seizure and delayed emergence from anesthesia resulting from remote cerebellar hemorrhage after lumbar spine surgery: a case report. Korean J Anesthesiol. 2012;63:270–3.View ArticlePubMedPubMed CentralGoogle Scholar
  17. Mikawa Y, Watanabe R, Hino Y, Ishii R, Hirano K. Cerebellar hemorrhage complicating cervical durotomy and revision C1-C2 fusion. Spine. 1994;19:1169–71.View ArticlePubMedGoogle Scholar
  18. Morofuji Y, Tsunoda K, Takeshita T, Hayashi K, Kitagawa N, Suyama K, et al. Remote cerebellar hemorrhage following thoracic spinal surgery. Neurol Med Chir (Tokyo). 2009;49:117–9.View ArticlePubMedGoogle Scholar
  19. Nakazawa K, Yamamoto M, Murai K, Ishikawa S, Uchida T, Makita K. Delayed emergence from anesthesia resulting from cerebellar hemorrhage during cervical spine surgery. Anesth Analg. 2005;100:1470–1.View ArticlePubMedGoogle Scholar
  20. Pallud J, Belaïd H, Aldea S. Successful management of a life threatening cerebellar haemorrhage following spine surgery: a case report. Asian Spine J. 2009;3:32–4.View ArticlePubMedPubMed CentralGoogle Scholar
  21. Takahashi Y, Nishida K, Ogawa K, Yasuhara T, Kumamoto S, Niimura T, et al. Multiple intracranial hemorrhages after cervical spinal surgery. Neurol Med Chir (Tokyo). 2012;52:643–5.View ArticlePubMedGoogle Scholar
  22. Thomas G, Jayaram H, Cudlip S, Powell M. Supratentorial and infratentorial intraparenchymal hemorrhage secondary to intracranial CSF hypotension following spinal surgery. Spine. 2002;27:E410–2.View ArticlePubMedGoogle Scholar
  23. Ulivieri S, Neri L, Oliveri G. Remote cerebellar haematoma after lumbar disc surgery. Case report. Ann Ital Chir. 2009;80:219–20.PubMedGoogle Scholar
  24. Yang K-H, Han JU, Jung J-K, Lee DI, Hwang S-I, Lim HK. Cerebellar hemorrhage after spine fixation misdiagnosed as a complication of narcotics use: a case report. Korean J Anesthesiol. 2011;60:54–6.View ArticlePubMedPubMed CentralGoogle Scholar
  25. Yoo JC, Choi JJ, Lee DW, Lee S. Remote cerebellar hemorrhage after intradural disc surgery. J Korean Neurosurg Soc. 2013;53:118–20.View ArticlePubMedPubMed CentralGoogle Scholar
  26. Lyons M, Windgassen E, Kinney C, Johnson D, Birch B, Boucher O. Thoracic meningioma masquerading as chronic abdominal pain. Turk Neurosurg. 2012;22:365–7.PubMedGoogle Scholar
  27. Angevine PD, Kellner C, Haque RM, McCormick PC. Surgical management of ventral intradural spinal lesions. J Neurosurg Spine. 2011;15:28–37.View ArticlePubMedGoogle Scholar
  28. Joaquim AF, Almeida JP, dos Santos MJ, Ghizoni E, de Oliveira E, Tedeschi H. Surgical management of intradural extramedullary tumors located anteriorly to the spinal cord. J Clin Neurosci. 2012;19:1150–3.View ArticlePubMedGoogle Scholar

Copyright

© Suzuki et al.; licensee BioMed Central. 2015

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Advertisement