Abstract
Background:The intraparenchymal supratentorial hemorrhages after interventions of the posterior fossa is a very rare complication, with very little literature and its precise incidence is unknown (range of 0.4–1.6%). It possesses potentially an etiology diverse from that associated with other postoperative bleeding.Case Description:A white, 23-year-old female, with no history of coagulation disorders or other diseases, was referred to our hospital with a large ependymoma, which extended from the floor of the fourth ventricle, emerged from the foramen of Magendie and descended to the C2 level. The patient was submitted to surgical treatment and during resection of the lesion, when near the vagal trigone, the patient presented great pressure lability. In the immediate postoperative period, the patient did not have a level of consciousness sufficient to tolerate extubation. Brain computed tomography (CT) was carried out, which showed multiple supratentorial hemorrhages. On the ninth day of the postoperative period, there was a sudden neurological worsening and anisocoria. A new brain CT was carried out [Figure 4], which demonstrated a diffuse cerebral edema. In spite of the introduction of clinical measures for the control of diffuse cerebral edema, the patient evolved to brain death.Conclusions:The principal measures in the management of these cases include early diagnosis, detection of possible coagulation disorders, continual monitoring, and maintenance of adequate cerebral perfusion. Surgical treatment is recommended in cases of the presence of mass effect or diffuse edema not yielding to clinical treatment. High rates of mortality and morbidity are observed.
Highlights
ConclusionsThe principal measures in the management of these cases include early diagnosis, detection of possible coagulation disorders, continual monitoring, and maintenance of adequate cerebral perfusion
The intraparenchymal supratentorial hemorrhages after interventions of the posterior fossa is a very rare complication, with very little literature and its precise incidence is unknown
Postoperative intracerebral hemorrhage remote from the operative site is a rare occurrence in the neurosurgical field, especially rare when it occurs in the supratentorial compartment after interventions to the posterior fossa
Summary
The principal measures in the management of these cases include early diagnosis, detection of possible coagulation disorders, continual monitoring, and maintenance of adequate cerebral perfusion. We report the case of a patient submitted to resection of an ependymoma in the floor of the fourth ventricle who presented multiple supratentorial hemorrhages after surgery. We undertook further a review of the literature on the epidemiology, treatment, and clinical evolution of patients with supratentorial hemorrhages after interventions in the posterior fossa. A brain computed tomography (CT) was carried out immediately after surgery [Figure 3], which showed multiple supratentorial hemorrhages. The patient evolved in the days following with spontaneous opening of the eyes, and obeying commands, but continued in mechanical ventilation as she did not protect the airway effectively. In spite of the introduction of clinical measures for the control of diffuse cerebral edema, the patient evolved to a condition of brain death.
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