Case Report

Does Ventricular Opening Promote Remote
Cerebellar Haemorrhage?
Ventrikül Açılımı Uzak Serebellar Kanamaya Neden Olur mu?
Ibrahim ZIyal1, Burcak BIlgIner1, Kivilcim Yavuz2, Cezmi Turk1, Caglar Ozgur1, Kemal BenlI1
1Hacettepe University, Faculty of Medicine, Department of Neurosurgery, Ankara, Turkey
2Hacettepe University, Faculty of Medicine, Department of Radiology, Ankara, Turkey

Correspondence address: Burcak BIlgIner / E-mail: [email-masked]

ABSTRACT
Cerebellar haemorrhage after supratentorial craniotomy is a rare complication Because of its significant morbidity and mortality rates, being
aware of this complication is important for early diagnosis. In a 30-year-old male with multiple intracranial cavernomas, remote cerebellar
haemorrhage (RCH) was observed after removal of symptomatic left temporal lesion. The lateral wall of the temporal horn that was tightly
attached to the cavernoma was also opened and excessive drainage of the CSF occurred. The haemorrhage is attributed to opening of the
ventricle wall and excessive drainage of cerebrospinal fluid (CSF) during the procedure.
Keywords: Temporal, Cavernoma, Haemorrhage

ÖZ
Supratentoryal kranyotomilerden sonra serebellar kanama görülmesi nadir bir komplikasyondur. Önemli derecede morbidite ve mortaliteye
neden olması sebebiyle bu komplikasyonun farkında olmak erken tanı için önemlidir. Çoklu intrakranyal kavernoması olan 30 yaşındaki erkek
hastada, sol temporaldeki semptomatik lezyonun çıkarılmasını takiben uzak serebellar kanama tespit edildi. Kavernom duvarına sıkıca yapışık
olan lateral ventrikül temporal hornu ameliyatta açılarak fazla miktarda beyin omurilik sıvısı drene oldu. Kanama nedeni olarak ameliyat
esnasında açılan ventrikül duvarından fazla miktarda beyin omurilik sıvısının kaybı düşünüldü.
ANAHTAR SÖZCÜKLER: Temporal, Kavernom, Kanama

Introduction
Remote cerebellar haemorrhage (RCH) is usually a benign
complication of supratentorial neurosurgical procedures
(1, 2, 3, 4, 5, 6, 7). Although the entity is attributed to
supratentorial craniotomies, the main point seems to be
sinking of cerebellum and stretching of vascular structures
following excessive drainage of the cerebrospinal fluid (CSF)
(3, 4, 5, 6). Here, we report a case of RCH in a patient with
multiple cavernomas which occurred following removal of
the symptomatic lesion. The ventricle wall was opened during
the operation and excessive CSF was drained.
Case Report
A 30-year-old male admitted to our clinic with generalized
seizure which was present for 6 years. He was using sodium
valproate 500 mg three times a day. His magnetic resonance
imaging (MRI) scans demonstrated multiple cavernomas in
the right frontal juxtacortical (Figure 1A) and parietal (Figure
1B) and in left frontal (Figure 1C) and temporal (Figure 1D)
locations. The electroencephalogram (EEG) revealed that the
left temporal cavernoma was responsible for his seizures.
An operation was planned and ten days before the operation
sodium valproate was stopped to eliminate excessive

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intraoperative bleeding. The patient was operated via left
temporal craniotomy and the left cavernoma was removed
totally. The lateral wall of the temporal horn that was tightly
attached to the cavernoma was also opened and excessive
drainage of the CSF occurred. The postoperative MRI scans
revealed total removal of the cavernoma and also a left mild
cerebellar hemispheric haemorrhage (Figure 2A, B). On the
first postoperative day, the patient did well. The following
day, the patient suffered from severe headache and ataxia.
His follow-up computed tomographic (CT) and MRI scans
demonstrated left intracerebellar haemorrhage without
any remarkable mass effect (Figure 3A, B). The patient was
followed conservatively and did well one week after the
operation. He did not mention any seizure on late follow-up
examinations.
Discussion
RCH after supratentorial craniotomy is usually a self-limiting
phenomenon that should not be mistaken with other
pathological conditions. However, it does not seem that the
supratentorial craniotomy is the main factor for this entity.
As speculated before, opening of cisterns and the ventricular
system may cause CSF hypovolemia resulting in cerebellar
sagging, transient occlusion of cerebellar bridging veins,
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Ziyal I. et al: Does Ventricular Opening Promote Remote Cerebellar Haemorrhage?

A

B

C

A

D

B

leading to haemorrhagic infarction and haemorrhage (3, 6,
7). Downward displacement of the cerebellum after excessive
drainage of CSF may also cause tearing of the superior
cerebellar vein.
On the other hand, RCH was observed after aneurysm, tumor,
epilepsy and neurotrauma procedures. In the literature, there
are also some RCH cases which were present after removal of
a cavernoma (1, 3). However, as far as we know this is the first
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Figure 1: Preoperative axial T2weighted MR images show multiple
cavernomas in the right frontal
juxtacortical (A) and parietal (B)
and in left frontal (C) and temporal
(D) locations with their typical
hemosiderin rim.

Figure 2: Postoperative axial T2weighted MR image (A) shows
total resection of left temporal
cavernoma with small amount
of postoperative collection left.
Coronal T2-weighted image
(B) shows the same collection
at left temporal region as well
as left cerebellar hemispheric
haemorrhage with mild mass effect
and minimal adjacent edema (black
arrow).

case of RCH with multiple cavernomas. We even do not think
that the nature of the lesion has some relationship with this
secondary event.
In this presented case, the cavernoma was attached to the
ventricle wall with a large surface. For total removal of the
cavernoma, opening of the temporal horn and partial removal
of the ventricle wall was necessary. Consequently, excessive
CSF was drained from the ventricle. Thereafter, the cerebellum

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Ziyal I. et al: Does Ventricular Opening Promote Remote Cerebellar Haemorrhage?

A

B

sank downward with stretching of vascular structures that
caused the cerebellar haemorrhage. Even though we stopped
sodium valproate 10 days before the surgical procedure and
the preoperative bleeding parameters were within normal
ranges, the RCH might have been precipitated by this agent.
In conclusion, opening of the cisterns and ventricles during
a supratentorial procedure causes excessive drainage of CSF
that may lead to RCH. Controlled drainage of CSF is essential
if possible.
References
1. Amini A, Osborn AG, McCall TD, Couldwell WT: Remote
cerebellar hemorrhage. AJNR 27: 387-390, 2006
2. Bilginer B, Oguz KK, Akalan N, Spencer DD: Remote
cerebellar hemorrhage and iliofemoral vein thrombosis after
supratentorial craniotomy. Neurocrit Care 8: 283-285, 2008

Figure 3: Axial CT scan (A) and MRI
gradient echo scan (B) obtained 36
hours after surgery shows the left
cerebellar haemorrhage with typical
streaky, curvilinear bleeding pattern
with blood in the cerebellar sulci.
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Cerebellar hemorrhage after supratentorial craniotomyreport of three cases. Neurol Med Chir (Tokyo) 30: 738-743,
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