Arch Orthop Trauma Surg (2013) 133:1645–1648
DOI 10.1007/s00402-013-1867-6

ORTHOPAEDIC SURGERY

Remote cerebellar haemorrhage after lumbar spine surgery:
case report
J. M. Cavanilles‑Walker · S. O. Tomasi · F. Sgier ·
M. Kröber

Received: 25 June 2013 / Published online: 12 October 2013
© Springer-Verlag Berlin Heidelberg 2013

Abstract Remote cerebellar haemorrhage (RCH) is a
well-described complication of supratentorial surgical procedures with an incidence ranging between 0.2 and 4.9 %,
but is a rare complication of spinal surgery. We report a
case of RCH in a 65-year-old woman who showed sudden mental deterioration 48 h after lumbar spinal surgery,
which was complicated by incidental dural tearing with
minimal CSF loss. Brain CT scan revealed hypodense areas
compatible with acute infarction involving mostly the left
cerebellar hemisphere. No cerebral bleeding was observed.
MRI was also performed revealing small cerebellar areas
of acute infarction mainly relating the vermis and the left
postero-inferior cerebellar hemisphere with haemorrhagic
transformation and mass effect in the posterior fossa producing acute hydrocephalus. Haematoma removal was initially attempted by means of a suboccipital craniotomy. An
external ventricular derivation was placed in a second procedure 24 h later due to the persistence of ventricular dilatation. At discharge the patient was only showing a slight
dysmetria with the fine motor skills of hands and fingers.
All cases of RCH after spinal surgery reported in the literature are invariably associated to iatrogenic dural tearing;
although CSF loss seems to play the key role in the pathogenesis of this rare complication, the exact pathophysiology of this condition still remains undetermined.

Keywords Cerebellum · Remote cerebellar
haemorrhage · Postoperative complication · Dural tear ·
Spinal surgery

Introduction
Although most of spinal surgery complications are implant
related or postoperative wound infections, neurologic complications such as nerve root lesion, epidural haematoma, epidural abscess or dural tearing are not infrequent. Dural tearing
during spinal surgery has a reported incidence ranging from
3.5 to 17.4 % [1]. However, remote cerebellar haemorrhage
(RCH), which develops distant to the site of surgery, after spinal surgery is a rare complication with a reported incidence of
0.08 % [2–5]. Interestingly, all the cases reported in the literature are invariably related to intraoperative unintended durotomy and cerebrospinal fluid (CSF) leakage [3, 5, 6]. Although
loss of CSF seems to play the key role in the pathogenesis
of this complication, the exact pathophysiology of this condition still remains undetermined [7]. Some authors suggest
that RCH can occur due to cerebellar downward sag resulting from CSF leakage that might injury the cephalic bridging
cerebellar veins leading to haemorrhagic venous infarction [3,
8]. We report a further case in which RCH occurred after spinal surgery complicated with dural tearing, review the literature, and discuss possible causative factors for this probably
underreported complication of spinal surgery.

J. M. Cavanilles‑Walker · M. Kröber
Spine Center, Klinik St. Anna, St. Anna‑Strasse, 32,
6006 Luzern, Switzerland

Case report

S. O. Tomasi (*) · F. Sgier
Neurological and Spine Surgery, Klinik St. Anna,
St. Anna‑Strasse, 32, 6006 Luzern, Switzerland
e-mail: ottavio.tomasi@gmail.com

A 65-year-old woman with an otherwise unremarkable past
medical history was taken to surgery after failure of conservative management for low back pain and neurogenic

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Fig. 1  Preoperative brain CT: hypodensity in the cerebellar hemisphere, left more than right, a finding compatible with acute ischemic
infarct and beginning acute hydrocephalus

claudication secondary to lumbar spinal canal stenosis. The
patient underwent instrumented postero-lateral fusion and
decompression from L2 to L5 with additional transforaminal interbody fusion at L3–4 and at L4–5. During the procedure accidental dural tearing with minimal CSF leakage
occurred. The dural tear was immediately sutured in watertight fashion and a subfascial drain with negative pressure was placed at the end of the procedure. The patient
immediate postoperative course was uneventful. No clear
or serous fluids were observed in the drainages suggesting
that a possible CSF leakage had occurred postoperatively.
However, 48 h postoperatively the patient experienced
a sudden change in her neurological status and presented
with slurred language, somnolence and temporo-spatial
disorientation, with Glasgow Coma Scale 13.
Fig. 2  Preoperative brain MRI
(a axial T2, b coronal T2): acute
cerebellar infarct in the vermis,
in the left posterior–inferior
cerebellar hemisphere, less
in the right hemisphere, with
haemorrhagic transformation
and mass effect with compression in the posterior fossa and
acute hydrocephalus

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Arch Orthop Trauma Surg (2013) 133:1645–1648

A brain CT scan (Fig. 1) was immediately performed
revealing hypodensity in the cerebellar hemispheres, left
more than right, suggesting an acute ischemic infarct and
early signs of acute hydrocephalus. A brain MRI (Fig. 2)
showed acute cerebellar infarct in the vermis and in the
left posterior–inferior cerebellar hemisphere with minor
involvement of the right hemisphere. Haemorrhagic transformation and mass effect with compression in the posterior fossa and acute hydrocephalus were also present.
An angio-MR was also performed resulting negative for
AVM. No other intracerebral lesions were documented.
Laboratory studies, including platelet count, prothrombin
time, and partial thromboplastin time, were within normal
ranges. Due to the findings and the clinical evolution it was
decided to perform a suboccipital craniectomy to achieve
haematoma removal and cerebellar decompression. 24 h
later it was necessary to place an external ventricular derivation (EVD) due to the persistence of hydrocephalus, confirmed in a postoperative brain CT. A brain MRI (Fig. 3)
predischarge showed a regression of the haemorrhage and a
normalisation in the width of the ventricular system.
When the patient was finally discharged from the ICU,
11 days after the operation, she was showing dysdiadochokinesia and a dysmetria in both hands and fingers, and
a central vertigo. At hospital discharge the patient’s neurological physical examination was normal except for slight
dysmetria with the fine motor skills of hands and fingers
and transitory subjective vertigo.

Discussion
Most of spontaneous perioperative intracranial haemorrhages are related to diverse causes such as use of anticoagulants, high arterial blood pressure or intracranial vascular

Arch Orthop Trauma Surg (2013) 133:1645–1648

1647

Fig. 3  Brain MRI predischarge
(a axial T2, b coronal T2):
status following osteoplastic
suboccipital craniotomy and
evacuation of cerebellar haematoma on both sides, left more
than links

abnormalities. However, some reports have established that
loss of CSF after dural tearing might be another important factor in the pathogenesis of intracranial haemorrhage
during or after spine surgery [3, 5, 9]. Dural tearing is a
well-known complication of spinal surgery, with a reported
incidence ranging from 3.5 to 17.4 % [1], being associated
to many different conditions such as pseudomeningocele,
CSF fistula formation, meningitis, arachnoiditis, postural
headache, nerve root or brainstem herniation, cerebellar
dysfunction, or intracranial haemorrhage in different locations [7]. First described by Chadduck in 1981 [10], RCH
after spinal surgery has been sporadically reported in the
English literature especially in the last years. All the cases
reported were invariably associated to accidental, noticed
or unnoticed, intraoperative dural tearing and CSF leak
showing neurological symptoms between immediate postoperative and 72 h after surgery [8].
According to the literature it seems that RCH can
occur after any type of spinal surgery in which CSF leak
has occurred during or after surgery, regardless of age,
sex, pathology [8] or perioperative patient position [11].
Although there is no agreement on the pathological mechanisms for RCH, most authors seem to agree on two facts:
RCH has a venous origin and is a result of intraoperative
or postoperative loss of CSF [3, 12]. The venous origin of
RCH [11, 13] can be supported by the evidence that, while
arterial bleeding tends to be unilateral, RCH is bilateral,
and that the bleeding is generally located in the upper vermis and cerebellar sulci, where the cerebellar draining veins
are located [12]. Regarding the intraoperative or postoperative loss of CSF as a potential cause of RCH, all cases of
RCH after spinal surgery reported are related to CSF leak.
Several authors suggest that a rapid leak of a large amount
of CSF would lead to caudal sagging of cerebellum [11].

The ‘cerebellar sag’ can cause venous occlusion or arterial
infarction, which can be followed by reperfusion haemorrhage or venous bleeding secondary to increased venous
pressure [11]. Most authors agree in the fact that a rapid
leak of a large amount of CSF may be required for cerebellar haemorrhage to occur. Although this might be right, in
our opinion this is controversial due to the fact that in most
of the reports the amount of CSF leak was not measured,
and RCH with minor CSF loss (as in our case) after lumbar
drainage has been reported in two patients [13].
Brain computed tomography (CT) or magnetic resonance image (MRI) allows an immediate diagnosis of this
complication. According to Brockmann [14] RCH has
characteristic image findings consistent with bleeding of
venous origin located in the upper aspect of the vermis
and folia bilaterally, and shows a curvilinear configuration
alternating hyperdense (blood) and hypodense (cerebellum)
stripes. These findings seen on MRI or CT are described
as the ‘Zebra sign’. Zebra-pattern haemorrhage seems to be
typical in a postoperative loss of CSF, which should always
be considered on presentation of this bleeding pattern [15].
RCH can be asymptomatic being detected incidentally
on radiological examinations. When symptomatic the clinical presentation may vary from dizziness, minor headache
or symptoms not typical for a cerebellar lesion [3, 5, 6, 16],
to a cerebellar or brainstem dysfunction, and even death in
some cases depending on the size of the haemorrhage [17].
Small bleedings are managed conservatively and followed
with serial imaging and usually they have good outcomes;
while larger RCH has a greater risk of acute obstructive
hydrocephalus and brainstem compression, and requires
immediate surgical decompression [4, 8]. Compression
of fourth ventricle and subsequent non-communicating
hydrocephalus should be managed with CSF diversion

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procedures [8]. Large bleedings still show favourable outcomes with complete recovery or mild remaining neurological symptoms in more than 50 % of all cases, while death
can occur in 10–15 % of cases [18].
Like all the cases of RCH after spinal surgery reported
previously in the literature, our case presented perioperative incidental dural tearing and consequent leak of CSF,
although in our case CSF loss was minimal and the tear
was immediately repaired with no postoperative CSF leakage. According to the literature, the authors believe that
dural tearing and the consequent CSF loss must be responsible for the development of RCH in our patient. About 30
cases of RCH after spinal surgery have been reported to
date, and all of them related to dural tearing with CSF loss.
Considering that the reported incidence of incidental dural
tear during spinal surgery is quite significant (between 3.5
and 17.4 %) [1] and the large number of spine surgeries
performed worldwide every year, it seems reasonable to
think that there are much more cases of RCH than those
actually reported probably because most cases consist of
small bleedings that course asymptomatic. Probably these
cases are not detected because postoperative cranial CT is
not routinely performed after spinal surgery [9]. Usually
most of the RCH cases consist in small bleedings coursing sub-clinically, and only a very small number of cases,
where dural tearing and CSF loss occurred, become symptomatic. Whether we need further investigation to stabilise
if the symptomatic cases are exclusively due to CSF loss or
due to other unidentified causative agents.

Conclusions
RCH is a rare, and probably underreported, complication
of spinal surgery associated to intraoperative dural rupture
with CSF loss during or after surgery. The real incidence
of this event is not known because imaging of the brain is
usually performed in symptomatic patients, and asymptomatic bleedings may occur more often than expected.
Although showing generally a favourable outcome, RCH
is a potentially life-threatening complication that must be
kept in mind in any patient with a declining neurological
status or even in those with minor headache or not typical
symptoms of a cerebellar or cerebral lesion, after spine surgery associated with CSF loss. In these situations, brain CT
or MRI should be achieved, and if a diagnosis of RCH is
confirmed, a surgical treatment should be immediately performed in order to improve the patient outcome.
Conflict of interest The authors have no conflicts of interest to
declare.

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Arch Orthop Trauma Surg (2013) 133:1645–1648

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