Neurol Med Chir (Tokyo) 44, 294¿297, 2004

Remote Cerebellar Hemorrhage Following Supratentorial
Craniotomy
—Case Report—
Takashi MARUYAMA, Keisuke ISHII, Mitsuo ISONO, Tatsuya ABE,
Minoru FUJIKI, and Hidenori KOBAYASHI
Department of Neurosurgery, Oita University School of Medicine, Oita

Abstract
A 63-year-old man presented with sudden severe headache. Computed tomography (CT) demonstrated
subarachnoid hemorrhage. Cerebral angiography demonstrated an aneurysm of the anterior communicating artery. Left frontotemporal craniotomy and neck clipping of the aneurysm via the pterional
approach were performed. CT obtained 18 hours after surgery revealed cerebellar hemorrhage, and
magnetic resonance (MR) imaging 17 days postoperatively demonstrated that the hemorrhage was
located within the folia. Neurological examination after surgery revealed slight dysarthria after
drainage of cerebrospinal fluid (CSF) but no other neurological deficits. Follow-up CT and MR imaging
showed characteristic findings of postoperative cerebellar hemorrhage clearly different from those of
hypertension. The cerebellar hemorrhage was probably secondary to overdrainage of CSF. He was
discharged without deficits.
Key words: cerebellar hemorrhage, complication,
ruptured cerebral aneurysm, suction drainage

Introduction

craniotomy,

subarachnoid hemorrhage,

severe headache. Twenty minutes later, he was
brought to our hospital by ambulance. On admission, his consciousness was alert and there were
no focal symptoms. Computed tomography (CT)
showed subarachnoid hemorrhage (Fig. 1). Cerebral
angiography demonstrated an aneurysm of the
anterior communicating artery, but no other
aneurysms or vascular anomalies including the
posterior fossa (Fig. 2). In addition, there was no
venous return lag or obstruction of the sinuses or
bridging veins. He had no history of arterial
hypertension or coagulation disorder.
The following day, surgery was performed in the
supine position with the head rotated 459 to the
right. Left frontotemporal craniotomy and neck
clipping of the aneurysm via the pterional approach
were performed. Before the dura mater was opened,
300 ml of 20% mannitol was administered. His blood
pressure remained within normal limits throughout
the surgical procedure, but transient hypertension
(maximal systolic blood pressure 200 mmHg) was

Intracranial hemorrhage following surgery is well
known, but cerebellar hemorrhage is rare as a
complication of supratentorial craniotomy with an
incidence of 0.08%12) to 0.6%.6) The incidence of
cerebellar hemorrhage is especially high at 12.9% in
patients who underwent temporal lobe resection.6)
Furthermore, the frequency of posterior fossa
hemorrhage after clipping of an anterior circulation
aneurysm was 3.5%, much higher than in other
reports.3) This complication may occur not only
after craniotomy but also after spinal surgery.2,4,8,10)
We describe a case of cerebellar hemorrhage
which
occurred
after
left
frontotemporal
craniotomy and neck clipping of a ruptured cerebral
aneurysm.

Case Report
A 63-year-old man presented with sudden onset of

Received March 13, 2003;
Accepted January 16, 2004
Author's present address: K. Ishii, M.D., Department of Neurosurgery, Helsinki University Central Hospital, Helsinki,
Finland.

294

Cerebellar Hemorrhage Following Craniotomy

Fig. 3
Fig. 1

Fig. 2

Computed tomography scan on admission
demonstrating subarachnoid hemorrhage
without cerebellar hemorrhage.

Preoperative left internal carotid angiogram
(left oblique projection) demonstrating an
aneurysm of the anterior communicating
artery, but no other aneurysms or vascular
anomalies including the posterior fossa.

observed at the end of surgery. During wound
closure, a subgaleal suction drain tube was inserted
and attached to a suction drainage system while the
patient was still in the operating room. He awoke
from anesthesia with no problems, and there were
no remarkable neurological deficits. Ninety minutes
after wound closure, 250 ml of cerebrospinal fluid
(CSF), mixed with blood, was drained. Thereafter,

Neurol Med Chir (Tokyo) 44, June, 2004

295

Computed tomography scan 18 hours
postoperatively demonstrating bilateral and
symmetrical cerebellar hemorrhage spreading along the cerebellar fissure or folia.

the CSF drainage was gradually decreased to total
280 ml 6 hours later, and 310 ml when stopped 13
hours later. There were no remarkable neurological
symptoms or vital changes suggesting an intracranial incident during this time. However, in retrospect,
he manifested slight dysarthria when the 250 ml of
fluid was drained.
Preoperative and postoperative laboratory studies
showed the prothrombin times, partial thromboplastin times, and platelet counts were within the
normal ranges. Routine CT obtained 18 hours
postoperatively demonstrated bilateral cerebellar
hemorrhage (Fig. 3). The suction drainage tube was
removed on the second operative day. Magnetic
resonance (MR) imaging 17 days postoperatively
demonstrated hemorrhage within the cerebellar
folia underneath the tentorium (Fig. 4). His symptoms gradually improved and follow-up CT revealed that the hemorrhage had gradually been
absorbed and had disappeared. Cerebral angiography 14 days postoperatively demonstrated
successful clipping of the aneurysm and no other
abnormal findings as noted preoperatively. He was
free of symptoms at discharge.

Discussion
Cerebellar hemorrhage following supratentorial
craniotomy may occur as an intraoperative or
postoperative event. However, the timing of the
hemorrhage occurred is difficult to determine,
because postoperative CT is generally not performed

T. Maruyama et al.

296

Fig. 4

Axial T1-weighted (left), axial T2-weighted (center), and sagittal T1-weighted (right) magnetic
resonance images 17 days postoperatively demonstrating cerebellar hemorrhage within the
cerebellar folia underneath the tentorium.

immediately after surgery and most hemorrhages
are detected on routine follow-up CT. A retrospective study analyzing early postoperative and followup CT indicated that cerebellar hemorrhage occurred as a postoperative rather than an intraoperative event.6) In our case, routine CT obtained 18
hours after craniotomy demonstrated cerebellar
hemorrhage, and follow-up CT and MR imaging
showed no progression of the hemorrhage, but these
findings cannot indicate the time of occurrence.
However, the patient did not manifest dysarthria on
awaking from the anesthesia, indicating postoperative occurrence.
The pathophysiological mechanism of cerebellar
hemorrhage following craniotomy remains unclear,
although remote cerebellar hemorrhage may be
venous in origin.3,5–7,11,12,16) Two mechanisms were
mainly considered in previously reported cases.
First, intracranial hypotension due to removal of a
supratentorial space-occupying mass or CSF loss
induces a critical increase in the transluminal
pressure of veins or venules resulting in tearing of
these vessels.6,7,12,15) Second, intracranial hypotension causes displacement or sagging of the cerebellum, and stretching of the cerebellar veins which
may then tear.13,15,16) The characteristic CT and MR
imaging findings clearly differ from those of hypertension, so strongly support the idea that postoperative cerebellar hemorrhage is venous in origin.
Cerebellar hemorrhage as a complication of
supratentorial surgery is located parallel to the
cerebellar folia and fissures.3,9,12,14,16) In addition, the
hemorrhage is often bilateral and symmetrical. In
contrast, typical spontaneous cerebellar hemorrhage
occurs in the center of the cerebellar parenchyma
and usually does not involve the subarachnoid

space.
In our case, the image findings were especially
characteristic. The significant causative factor of
postoperative cerebellar hemorrhage appeared to be
overdrainage of CSF, because a large amount of CSF
(250 ml) mixed with blood was rapidly drained
only 90 minutes postoperatively. The intracranial
pressure must have changed quickly due to this
rapid loss of CSF. There are no previous details of
the amount of CSF drained in the early postoperative period. Our case strongly supports the hypothesis that the causative mechanism of this hemorrhage
is displacement or sagging of the cerebellum due
to overdrainage of CSF, leading to stretching and
tearing of the superior vermian veins and their
tributaries. However, the pathophysiological
mechanism of remote cerebellar hemorrhage following supratentorial craniotomy may be multifactorial,
and specific causes are difficult to identify. Various
other major causative factors of postoperative
remote cerebellar hemorrhage have previously
been suggested, such as intraoperative rotation or
extension of the head,11,12) arterial hypertension,
and disturbance of coagulation due to the use of
heparin7) or valproic acid.12,15) Unfortunately, we
could not pinpoint the predictive factor of this complication in our case.
The prognosis for patients with postoperative
cerebellar hemorrhage is usually good, with
mild and transient neurological dysfunction.
However, several reported patients have had a poor
outcome.1,7,11) Careful intraoperative and postoperative care to manage the various risk factors, especially rapid overdrainage of CSF if suction drainage is
used, is required to avoid this complication.

Neurol Med Chir (Tokyo) 44, June, 2004

Cerebellar Hemorrhage Following Craniotomy

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Address reprint requests to: K. Ishii, M.D., Department of
Neurosurgery, Oita University School of Medicine,
1–1 Idaigaoka, Hasama–machi, Oita–gun, Oita
879–5593, Japan.
e-mail: keisuke＠med.oita-u.ac.jp