Case Report
Remote Cerebellar Haemorrhage: A Potential Iatrogenic
Complication of Spinal Surgery
Muhammad Atif Naveed ,
1
Rajiv Mangla ,
2
Hajra Idrees,
1
and Rashi I. Mehta
3
1
Department of Radiology, Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan
2
Department of Radiology, SUNY Upstate Medical University, Syracuse, NY, USA
3
Department of Radiology, West Virginia University, Morgantown, WV, USA
Correspondence should be addressed to Rashi I. Mehta; rashi.mehta@hsc.wvu.edu
Received 3 June 2018; Revised 26 July 2018; Accepted 27 August 2018; Published 16 September 2018
Academic Editor: Mehmet Turgut
Copyright © 2018 Muhammad Atif Naveed et al. Tis is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
We report the case of a 51-year-old man with no signifcant past medical history, who underwent elective revision spinal surgery and
subsequently developed intracranial hypotension, remote cerebellar haemorrhage (RCH), and mild hydrocephalus on the fourth
postoperative day. Remote cerebellar haemorrhage is a known complication of supratentorial surgery. Tis iatrogenic phenomenon
may also occur following spinal surgery, due to dural tearing and rapid cerebral spinal fuid (CSF) leakage, resulting in intracranial
hypotension and cerebellar haemorrhage. Tis complication may result in severe permanent neurologic sequelae; hence, it is of
pertinence to diagnose and manage it rapidly in order to optimise patient outcome.
1. Case Report
A 51-year-old male, with a remote previous history of L4-L5
spinal decompression and fusion, presented in our outpatient
clinic with worsening lower back pain. Physical examination
showed lumbar radiculopathy and neurogenic claudication,
while a magnetic resonance imaging (MRI) scan of the
lumbar spine revealed disc protrusions and high-grade spinal
canal stenosis at the L2-L3 and L3-L4 levels. Consequently,
he underwent elective spinal decompression revision surgery,
with an extension of instrumented fusion from L2-L5.
On experiencing new onset persistent headaches on the
second postoperative day, a computerized tomography (CT)
myelogram was performed, and showed CSF leakage from
a dural tear at the L3-L4 level (Figure 1). Soon afer the
CT myelogram, image-guided lumbar drain placement was
performed, and 8cc of fbrin glue was injected at the site of
the leak.
On the fourth postoperative day, an urgent unenhanced
CT scan of the head was performed afer the patient
developed altered mental status, confusion, disorientation,
and slurred speech. Te CT scan revealed areas of acute
haemorrhage in both cerebellar hemispheres, with mass
efect on the fourth ventricle and the brainstem and mild
obstructive hydrocephalus (Figure 2). Subsequent review of
nursing charts revealed excess CSF drainage over the previous
night; thus, immediate clamping of the lumbar drain was
performed, and an external ventricular drain (EVD) was
placed by the neurosurgery team. MRI scanning of the brain,
with and without contrast, revealed evidence of intracranial
hypotension (Figure 3).
On the fourteenth postoperative day, the patient had an
open surgical dural repair using direct suture closure, along
with DuraGen5 (a synthetic dural allograf), and fbrin glue.
Additionally, the lumbar drain was successfully removed.
Te patient’s subsequent hospital course was complicated
by deep venous thrombosis and respiratory failure, and he
was ultimately discharged to the rehabilitation unit afer EVD
removal, ten days afer the open dural repair surgery. No
residual neurological defcits were present at the time of
discharge.
2. Discussion
Remote cerebellar haemorrhage (RCH) refers to a postoper-
ative parenchymal cerebellar haemorrhage, remote from the
Hindawi
Case Reports in Neurological Medicine
Volume 2018, Article ID 5870584, 4 pages
https://doi.org/10.1155/2018/5870584