Abstract
IntroductionCerebellar hemorrhage remote from the operative site is an unpredictable and rare complication in neurosurgery, with reported rates of morbidity and mortality in the literature of 8.4% and 7.8%, respectively. The range of procedures associated with remote cerebellar hemorrhage is diverse and includes both supratentorial and spinal procedures that entail significant cerebral spinal fluid loss or resection of supratentorial content. We present here the first documented case of remote cerebellar hemorrhage after controlled supratentorial cerebral spinal fluid drainage by ventriculoperitoneal shunt, and discuss the proposed pathophysiology and treatment.Case presentationWe present the case of a four-month-old Saudi Arabian male baby who presented with progressive symptoms and signs of congenital hydrocephalus. An uneventful ventriculoperitoneal shunting was performed with our patient recovering smoothly in the immediate postoperative period. On the next day, he had frequent episodes of vomiting and became lethargic. An urgent computed tomography scan of his brain revealed mild ventricular decompression and unexpected cerebellar hemorrhage. The infant was put under close observation, with marked spontaneous improvement over 48 hours and complete resolution of the hemorrhage on a follow-up computed tomography brain scan two weeks later. On regular outpatient visits at one, three and twelve months, he had no neurological deficit.ConclusionRemote cerebellar hemorrhage is a complication that remains enigmatic in terms of both the underlying mechanism and clinical behavior. Our case revealed that the risk factors identified in the literature are not sufficient in predicting patients at risk of developing remote cerebellar hemorrhage. Our report also adds to the growing body of evidence challenging the currently accepted hypothesis explaining the pathomechanism of remote cerebellar hemorrhage. It thereby remains an unpredictable hazard that requires further study and increased awareness, as many cases in the literature are incidental findings.
Highlights
Cerebellar hemorrhage remote from the operative site is an unpredictable and rare complication in neurosurgery, with reported rates of morbidity and mortality in the literature of 8.4% and 7.8%, respectively
Our case revealed that the risk factors identified in the literature are not sufficient in predicting patients at risk of developing remote cerebellar hemorrhage
remote cerebellar hemorrhage (RCH) is a rare neurosurgical complication believed to be a result of significant cerebral spinal fluid (CSF) hypovolemia
Summary
RCH is a poorly understood disease whose pathophysiology is still a matter of controversy. Our case adds to the growing body of evidence challenging the current prevailing theory’s requirement of substantial CSF drainage. It is the authors' belief that there is no single underlying theory that explains all RCH cases, and that there are several subtypes, as evidenced by the varying morbidity observed between those caused by supratentorial and spinal procedures. Each of these subtypes is with their own underlying mechanisms that, along with certain patient- and procedure-related factors, converge to disrupt the infratentorial vascular bed. Had we been able to label him as such, we probably would have elected to use a programmable shunt, and employed a gradual decrease of intracranial pressure postoperatively to obtain even slower and more strictly controlled CSF drainage over several days
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