Abstract
BackgroundSubdural hematoma (SDH) at a remote operative site is uncommon following neurosurgical procedures. However, supratentorial SDH is one of the rare complications following microvascular decompression (MVD). We report a case of supratentorial SDH following MVD. The welling of cerebrospinal fluid (CSF) in the cerebellomedullary fissure was observed unexpectedly during the dissection. It is a signal case that can improve our understanding of the occurrence of such rare complications and of possible mechanisms.Case presentationA 54-year-old woman was diagnosed with left hemifacial spasm (HFS) and had been receiving botulinum toxin injections since 10 years before surgery. CSF welling-up in the cerebellopontine cistern was noticed by the surgeon during the arachnoid dissection. MVD was performed completely. A thin supratentorial SDH was found on the right side (contralateral) on immediate postoperative computed tomography (CT). The SDH was asymptomatic, and the size of hematoma did not increase in follow-up CT scans after surgery. During the follow-up period, she was relieved of HFS. CSF welling-up can be considered the time of initiation of the hemorrhage.ConclusionLimited case reports of supratentorial SDH following MVD have been published, and none of them have reported time of initiation of the hemorrhage. The phenomenon of abnormal CSF welling-up in the cistern could be a sign of remote supratentorial hemorrhage.
Highlights
Subdural hematoma (SDH) at a remote operative site is uncommon following neurosurgical procedures
We report a case of supratentorial SDH following microvascular decompression (MVD), which presented as welling-up of cerebrospinal
Preoperative magnetic resonance images (MRI) revealed the offending artery to be the posterior inferior cerebellar artery (PICA), which lies in close proximity to the area where the root of facial nerve exits the cranium (Fig. 1a)
Summary
Most of the cases with remote supratentorial SDH achieved good outcomes; some of the cases have the possibility of encountering devastating results. To prevent this rare complication, previous studies have suggested that excessive CSF drainage should be avoided and that CSF loss should be compensated with sufficient amounts of artificial CSF immediately before dural closure. The phenomenon of abnormal CSF accumulation in the cerebellomedullary cistern should be considered a sign to suspect unexpected supratentorial hemorrhage, even if transient. An immediate postoperative CT scan is recommended to detect the supratentorial hemorrhage in the patients who might need critical care and appropriate interventions
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