Copyright © 2020 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Delayed Supratentorial Intracerebral Hemorrhage After Posterior Fossa Acoustic Neuroma Surgery Bashar Abuzayed, MD,  Khaled Alawneh, MD, y Majdi Al Qawasmeh, MD, z Khalid Abdalla, MD, y Mai Al-Ali, MD, § and Liqaa Raffee, MD jj Abstract: A 72-year-old female patient was complaining from gradual loss of hearing in the left ear, left facial palsy with gait imbalance. Neuroimaging showed left cerebellopontine angle extra- axial mass and was diagnosed as acoustic neuroma. She was operated with left retromastoid suboccipital and gross total excision of the tumor was achieved. Early postoperative period was uneventful and brain computed tomographic (CT) scan in the postoperative day 1 showed gross total resection of the tumor without complications, and patient was discharged at the postoperative day 4. In the postoperative day 7, the patient showed decrease level of consciousness and brain CT scan showed a small hematoma in the anterior part of the left temporal lobe, which was evolved to large intraparanchymal hemor- rhage with midline shift in postoperative day 9. Key Words: Hemorrhage, posterior fossa, supratentorial I ntracerebral hemorrhage remote from operative site is a rare complication. The estimated incidence of supratentorial hemor- rhage after posterior fossa surgery is in the range of 0.4% to 1.6%. 1 On the contrary, it is associated with significant morbidity and mortality. 2 A few cases have been reported; however, the exact cause could not be determined. In this report, we are presenting an unusual case of delayed supratentorial intracerebral hemorrhage after posterior fossa surgery for acoustic neuroma. PATIENT PRESENTATION A 72-year-old female patient was complaining from gradual loss of hearing in the left ear with gait imbalance. Neurologic and otologic examination revealed total deafness in the left ear, left facial palsy (House-Brackmann Grade III), and positive Romberg test. Magnetic resonance imaging (MRI) showed left cerebellopontine angle cystic mass, widening the internal acoustic meatus, compressing the brain stem and characteristic for acoustic neuroma (Fig. 1A and B). She underwent a left retromastoid suboccipital craniectomy in park-bench position with head turned towards the right side. Intraoperatively, usual tumor bleeding was encountered, with no venous sinuses bleeding. Gross total excision of the tumor was achieved with preservation of the facial nerve. Early postoperative period was uneventful and brain computed tomographic (CT) scan in the post- operative day 1 showed gross total resection of the tumor without complications (Fig. 1C and D). Treatment with dexamethasone and prophylactic dose (40 mg/day) of low-molecular-weight heparin was continued until the discharge at the postoperative day 4. The histo- pathologic examination confirmed the diagnosis of acoustic neu- roma. In the postoperative day 7, the patient showed confusion and disorientation. Therefore, brain CT scan was obtained and showed a small hematoma in the anterior part of the left temporal lobe (Fig. 1E). The patient was accordingly admitted and treatment with mannitol was started. Blood tests for complete blood count, kidney function tests, Prothrombin time, active partial thromboplastin time, and international normalized ratio showed no abnormalities, excluding coagulopathy as an etiology. Blood pressure, oxygenation, and arterial blood gases were monitored and showed stability. In the postoperative day 9, the patient showed decrease level of conscious- ness with Glasgow Coma Scale (GCS) of 10. Brain CT scan showed large left temporal lobe intraparanchymal hemorrhage with midline shift (Fig. 1F). Treatment options, including surgical decompressive craniectomy, were discussed with the relatives and they refused the surgery and decision was made to continue as possible with medical treatment. The patient showed stable vital signs and GCS, and brain CT scan in the postoperative day 12 showed no changes. DISCUSSION Delayed supratentorial intracerebral hemorrhage occurring after posterior fossa surgery is a rare neurosurgical complication. According to a review study by de Albuquerque et al, 1 they found that the majority of cases were female (81.2%), and only 6.6% of cases were associated with coagulation disorders. There was no predominance of a specific location for hemorrhages. They also found that mortality from these bleedings is high (50%) and most morbidities are of severe type (25%). In the majority of cases, the bleeding was seen early within a few hours of the surgery, which suggested that this complication occurred during or soon after the surgery. 1 However, in our case From the  Gardens Hospital, Amman; y Department of Radiology; z Department of Neuroscience, Division of Neurology, Faculty of Medi- cine, Jordan University of Science and Technology, Irbid; § Department of Radiology, Gardens Hospital, Amman; and jj Department of Accident and Emergency, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan. Received March 21, 2020. Accepted for publication April 13, 2020. Address correspondence and reprint requests to Bashar Abuzayed, MD, Gardens Hospital, Al Sab Bin Jathamah St 20, Amman 11953, Jordan; E-mail: sylvius@live.com. The authors report no conflicts of interest. Copyright # 2020 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000006661 FIGURE 1. (A and B) Preoperative brain magnetic resonance imaging showing the left cerebellopontine angle acoustic neuroma. (C and D) Post-op day 1 computed tomographic (CT) scan showing gross total resection of the tumor without complications. (E) Post-op day 7 CT scan showing small hematoma in the anterior part of the left temporal lobe. (F) Post-op day 9 CT scan showing hematoma progression to large left temporal lobe intraparanchymal hemorrhage with midline shift. Brief Clinical Studies The Journal of Craniofacial Surgery  Volume 31, Number 6, September 2020 e592 # 2020 Mutaz B. Habal, MD