LETTER TO THE EDITOR Intracerebral hemorrhage after cranioplasty: an unpredictable treacherous complication due to reperfusion or possible systemic inflammatory response syndrome Paolo Missori 1 & Antonio Currà 2 & Simone Peschillo 1 & Francesco Fattapposta 3 & Danilo Toni 3 Received: 9 August 2017 /Accepted: 12 December 2017 # Springer-Verlag Italia S.r.l., part of Springer Nature 2017 Dear Editor, In case of malignant cerebral infarction and progressive neurological worsening, randomized controlled trials have demonstrated improved survival and functional outcome after decompressive craniectomy and dural expansion. The occurrence of an intracerebral hemorrhage after cranioplasty is extremely rare. To date, only four cases have been reported [1–4]. A 54-year-old man with an extensive left middle cerebral artery territory infarction and progressive neurological impairment (from NIHSS 18 to NIHSS 22) underwent decompressive craniectomy with removal of a large fronto-temporo-parietal bone flap. The patient regained consciousness after the procedure; however, motor right-sided hemiparesis and aphasia were unchanged (NIHSS 15). After 7 days, the patient was transferred to the rehabilitation unit. Ninety-three days later, because of good wound healing and the patient’ s desire, he was newly admitted to the hospital for autolo- gous bone flap repositioning. Preoperative control com- puted tomography (CT) did not show any abnormality except for a large left post-ischemic area in the fronto- temporal region. Routine screenings were in the normal range, and low-dose heparin 4000 IU and anti-epileptic drugs were in use. The cranioplasty was performed in 90 min, without complications. Immediately after awak- ening, the patient experienced a generalized epileptic sei- zure. Control CT disclosed a hemorrhage in the left cere- bellar hemisphere, with mild perilesional edema but no significant abnormalities in the post-ischemic area under the repositioned bone flap (Fig. 1a, b). Blood analysis showed hemoglobin was 12.6 g/dL (13.3 g/dL preopera- tive), the white cell count was 13,370 (6560 WC preop- erative), C-reactive protein was 39,900 μg/L (normal val- ue 100–6000 μg/L), and D-dimer was 1321 μg/L (normal value 0–550 μg/L). Serological protein was slightly re- duced from 7.4 to 6.9 g/dL. During the subsequent 12 h, the patient’ s level of consciousness deteriorated (GCS 8) and CT displayed an increase of the perilesional edema; therefore, a left suboccipital craniotomy was performed with removal of the cerebellar hemorrhage. The patient did not improve, and CT revealed the occurrence of left cerebellar, mesencephalic, and intraventricular hemor- rhages (Fig. 2). Control blood examinations showed acute reduction of the white cell count to 6050, hemoglobin to 8.2 g/dL, and serum protein to 4.7 g/dL. Systemic inflam- matory response syndrome (SIRS) was suspected, and the patient died 72 h after cranioplasty. The four cases report- ed thus far in the literature [1–4] were adults (mean age 66.75 years), with ischemic or hemorrhagic infarction in the brain tissue. As in our case, early or late closure of the bone defect did not appear to be related to the occurrence of the hemorrhage: two patients underwent bone flap re- positioning 2 months after decompressive craniectomy, while others underwent repositioning at 9 and 12 months after the procedure. Indeed, this complication appears to be more characteristic of patients with previous ischemic brain stroke (5/5: 100%). The hemorrhagic event after cranioplasty appears to be characterized by diffuse atypical distribution, which varies to * Paolo Missori missorp@yahoo.com 1 Department of Neurology and Psychiatry, Neurosurgery, BSapienza^ University of Rome, Viale del Policlinico, 155, 00185 Rome, Italy 2 Department of Medical-Surgical Sciences and Biotechnologies, Neurology Unit, Ospedale BA. Fiorini^ Terracina, LT, BSapienza^ University of Rome, Polo Pontino, Italy 3 Department of Neurology and Psychiatry, Neurology, BSapienza^ University of Rome, Rome, Italy Neurological Sciences https://doi.org/10.1007/s10072-017-3225-x