- Department of Neurosurgery, Santa Casa de Belo Horizonte, Minas Gerais, Brazil
- Department of Neurology and Neurosurgery, State University of Campinas, Campinas, São Paulo, Brazil
Lucas Alverne Freitas de Albuquerque
Department of Neurosurgery, Santa Casa de Belo Horizonte, Minas Gerais, Brazil
DOI:10.4103/2152-7806.153649Copyright: © 2015 de Albuquerque LAF. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: de Albuquerque LA F, Dourado JC, João Paulo Almeida, Costa BS. Multiple supratentorial intraparenchymal hemorrhage after posterior fossa surgery. Surg Neurol Int 19-Mar-2015;6:
How to cite this URL: de Albuquerque LA F, Dourado JC, João Paulo Almeida, Costa BS. Multiple supratentorial intraparenchymal hemorrhage after posterior fossa surgery. Surg Neurol Int 19-Mar-2015;6:. Available from: http://sni.wpengine.com/surgicalint_articles/multiple-supratentorial-intraparenchymal-hemorrhage-posterior-fossa-surgery/
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 [
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.
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. Its occurrence is associated with great morbidity and mortality.[
Haynes et al.[
In this work, 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 white, 23-year-old female, with no history of coagulation disorders or other diseases, was referred to our hospital with a history of neck pain that commenced 1 year ago, and about 6 months ago evolved with a loss of power and multiple falling episodes.
The general physical examination was normal. In the neurological examination, the patient was completely lucid, tetraparetic, 4/5 on the right and 3/5 on the left and hyperreflexia in the 4 members.
Magnetic resonance imaging (MRI) demonstrated the existence of a large lesion, suggestive of 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 median suboccipital craniotomy and C1 laminectomy in the park bench position with the left side down [
As a routine in our department, in the immediate postoperative period, we tried to wake up the patient and extubate. However, the patient did not have a level of consciousness sufficient to tolerate extubation, and was maintained under mechanical ventilation. Therefore a brain computed tomography (CT) was carried out immediately after surgery [
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. Vasoactive drugs (norepinephrine) were introduced to maintain the mean arterial pressure (MAP) >60 mmHg, as pressure lability continued to be present in the postoperative period, with adequate control initially.
On the fourth day after surgery, the patient presented symptoms of pneumonia and was treated with antibiotics with satisfactory response. The patient presented good parameters at the physiological monitoring with electrocardiogram (ECG), respiratory rate, invasive blood pressure (IBP), body temperature, arterial hemoglobin oxygen saturation (SpO2); and adequate intravascular volume. However, on the ninth day of the postoperative period, there was a sudden neurological worsening and anisocoria. A new brain CT was carried out [
A pathological anatomical examination confirmed the hypothesis of ependymoma.
Postoperative hemorrhages remote from the craniotomy site can occur after supra or infratentorial interventions. They are rare complications and normally associated to great morbidity and mortality.[
The intraparenchymal supratentorial hemorrhages after interventions of the posterior fossa possess potentially an etiology diverse from that associated with other postoperative bleeding [
In accordance with our review, there are 18 cases of supratentorial intraparenchymal hemorrhage after interventions to the posterior fossa, published in the literature. The majority of patients are females, 13/16 (81.2%) and middle-aged, mean age: 53.7 years old. Only 1/15 (6.6%) of the cases present associated coagulation disorders. In the majority of cases, the intervention to the posterior fossa was for tumor resection 13/18 (72.2%); Meningioma 5/13 (38.4%); acoustic neuroma 3/13 (23%); hemangioblastoma 2/13 (15.3%). The majority of patients were submitted to the surgery in the sitting position, 14/18 (77.7%). The diagnosis of distant hematoma occurred during the first hours after the procedure in 12/14 cases (85.7%).
There is no predominance of a specific location as focus for hemorrhages. Multiple bleeding focuses were observed in five patients (27.7%), and one of them presented a coagulation disorder.
The majority of patients evolved to death, 8/16 (50%). Severe deficiency, including hemiparesis and/or visual loss, was present in 4/16 (25%) of the cases, moderate deficiency in 3/16 (18.7%) and light deficiency in 1/16 (6.2%).
The case reported is the only one to present multiple bleeding sites soon after the surgery. In the case introduced by Vrettou et al.,[
In the majority of cases, the diagnosis of the bleeding was performed within a few hours of the surgery, which suggests that this complication occurred during or soon after the surgery.
Coagulation disorders can be the cause of this intraparenchymal bleeding at a distance, as in the case introduced by Vettrou et al.[
In the absence of predisposing factors, there exist some theories that attempt to explain the pathophysiology of the supratentorial intraparenchymal bleeding after surgery to the posterior fossa, including:[
Ample drainage of cerebrospinal fluid (CSF) in patients with lesions of the posterior fossa, submitted to surgery in the sitting position, may be associated with supratentorial bleeding because of the rapid reduction of the intracranial pressure. Such fact could cause rupture in the ventricular ependymal wall.[
As introduced by Cartier-Giroux et al.,[
Peri-hemorrhagic edema may be separated into an acute phase (0–48 h) and a delayed phase (maximal edema at the end of week two). Second, delayed processes start a few days after ictus with an activation of the coagulation cascade, thrombin production, and erythrocyte/hemolysis products inciting inflammation resembling a mixed picture of cytotoxic and vasogenic edema. Our patient presented a delayed deterioration probably secondary do peri-hemorrhagic edema.[
Intraparenchymal supratentorial hematomas after interventions of the posterior fossa where the patient does not awaken adequately or develops a new neurological deficiency should be suspect. The management varies case by case, always remembering, however, coagulation disorders and rigorous pressure control. Surgical treatment is reserved for lesions with mass effect and midline deviation. Bilateral decompressive craniectomy can be realized as an alternative for the treatment of diffuse cerebral edema not yielding to clinical treatment. Clinical treatment is based on the control of pressure lability, monitoring intracranial pressure in cases where there is a lowering of the level of consciousness, maintenance of adequate cerebral perfusion rate and the identification and treatment of potential coagulation disorders.
Supratentorial hemorrhage after resection of lesions in the posterior fossa is a rare phenomenon. It is potentially associated with ample drainage of CSF and the sitting position, which can generate excessive reduction of intracranial pressure and bleeding through injury to small bridging veins; and pressure lability during the removal of tumors next to the floor of the fourth ventricle. High rates of mortality and morbidity are observed. 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.
I agree with the authors that their use of a park bench position makes the more common explanations of supratentorial intracerebral hematoma following posterior fossa decompression, as being related to intraoperative patient position, unlikely. This is therefore a particularly interesting paper. Documentation is good. Hyper transient vasomotor instability in the face of work on the floor of the fourth ventricle is also a possibility. This can be missed during transfers, when monitoring can take a back seat to other pressing issues. Most modern monitors have a “trending” capability, which sometimes allows late review of time-based physiological parameters for clarification of the origin of problems.
Speculation on the etiology of the late deterioration is reasonable, albeit unproven. Norepinephrine may also have the capacity to mask an indolent progressive intravascular hypovolemia, particularly in the absence of central monitoring in the face of potential septic corporal transmural volume loss, which might exacerbate vasospasm. I have therefore preferred the use of hyperosmolar volume expansion coupled with beta-blockade as necessary, though the risk of rebound late swelling is to be guarded against, and is also a risk.
Finally, in at least one personal case (not published to date), basilar artery kinking has been documented, following supratentorial swelling late after subarachnoid hemorrhage, following deterioration and just prior to that patient's acute demise. Pressure differential from infratentorial decompression could potentially also lead to this basilar apex kinking, and therefore cause the same supratentorial ischemic compromise, though in this case this is pure speculation.
1. Agrawal A, Kakani A, Ray K. Extensive supratentorial hemorrhages following posterior fossa meningioma surgery. editors. J Surg Tech Case Rep. 2010. 2: 87-9
2. Brisman MH, Bederson JB, Sen CN, Germano IM, Moore F, Post KD. Intracerebral hemorrhage occurring remote from the craniotomy site. editors. Neurosurgery. 1996. 39: 1114-21
3. Bucciero A, Quaglietta P, Vizioli L. Supratentorial intracerebral hemorrhage after posterior fossa surgery. Case report. editors. J Neurosurg Sci. 1991. 35: 221-4
4. Cartier-Giroux J, Mohr G, Sautreaux JL. Supratentorial hemorrhage of hypertensive origin during operation: An unusual complication of surgery on the posterior fossa in the sitting position. editors. Neurochirurgie. 1980. 26: 291-4
5. Haines SJ, Maroon JC, Jannetta PJ. Supratentorial intracerebral hemorrhage following posterior fossa surgery. editors. J Neurosurg. 1978. 49: 881-6
6. Harders A, Gilsbach J, Weigel K. Supratentorial space-occupying lesions following infratentorial surgery: Early diagnosis and treatment. editors. Acta Neurochir (Wien). 1985. 74: 57-60
7. Kalfas IH, Little JR. Postoperative hemorrhage: A survey of 4992 intracranial procedures. editors. Neurosurgery. 1988. 23: 343-7
8. Kalkan E, Eser O. Supratentorial intracerebral hemorrhage following posterior fossa operation. editors. Neurol India. 2006. 54: 220-1
9. Kuramatsu JB, Huttner HB, Schwab S. Advances in the management of intracerebral hemorrhage. editors. J Neural Transm. 2013. 120: S35-41
10. Pandey P, Madhugiri VS, Sattur MG, Devi B I. Remote supratentorial extradural hematoma following posterior fossasurgery. editors. Childs Nerv Syst. 2008. 24: 851-4
11. Seiler RW, Zurbrugg HR. Supratentorial intracerebral hemorrhage after posterior fossa operation. editors. Neurosurgery. 1986. 18: 472-4
12. Standefer M, Bay JW, Trusso R. The sitting position in neurosurgery: A retrospective analysis of 488 cases. editors. Neurosurgery. 1984. 14: 649-58
13. Tondon A, Mahapatra AK. Superatentorial intracerebral hemorrhage following infratentorial surgery. editors. J Clin Neurosci. 2004. 11: 762-5
14. Vrettou CS, Stavrinou LC, Halikias S, Kyriakopoulou M, Kollias S, Stranjalis G, Koutsoukou A. Factor XIII deficiency as a potential cause of supratentorial hemorrhage after posterior fossa surgery. editors. Acta Neurochir (Wien). 2010. 152: 529-32
15. Waga S, Shimosaka S, Sakakura M. Intracerebral hemorrhage remote from the site of the initial neurosurgical procedure. editors. Neurosurgery. 1983. 13: 662-5
16. Wolfsberger S, Gruber A, Czech T. Multiple supratentorial epidural hematomas after posterior fossa surgery. editors. Neurosurg Rev. 2004. 27: 128-32