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Eur. Neurol. 24: 145-148 (1985)

Spontaneous Cerebellar Hemorrhage after Coronary Artery
Bypass Surgery
Douglas /•.. Andersona, José Billerb, Ronald R. Sehreiberc
•' Division of Neurosurgery (Department of Surgery). b Department of Neurology.c Division of Cardiology
(Department of Internal Medicine). Loyola University Medical Center, Maywood, 111., USA

Key Words. Cerebellar hemorrhage • Coronary artery bypass surgery • Cranial
computerized tomography

Introduction

Spontaneous parenchymatous brain hem­
orrhage accounts for approximately 10% of
all strokes in the United States [10], and con­
tinues to be associated with a high morbidity
and mortality rate [11]. Cerebellar hemor­
rhage itself represents about 10% of all spon­
taneous intracerebral hemorrhages, and may
produce a life-threatening syndrome. The
early clinical picture of a hemorrhage into the
cerebellum is characterized by headaches.

dizziness, vertigo, nausea, vomiting, and in­
ability to stand or walk [3]. In the vast major­
ity of instances, operative intervention is
necessary for survival and optimal outcome
[4-8]. Cranial computerized tomography
(CT) demonstrates accurately the localization
and dimensions of the hemorrhage as well as
the degree of vcntriculomcgaly and associ­
ated brain edema [9]. Cerebellar hemorrhage
is most commonly secondary to arterial hy­
pertension. but may occur with vascular mal­
formation. neoplasms, trauma, bleeding dis-

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Abstract. A patient had a spontaneous intracercbellar hemorrhage following coronary
artery bypass surgery. His clinical course, characterized by headaches, gait ataxia, and then
signs of brain stent compression, is emphasized. Following diagnosis by cranial computerized
tomography, successful surgical decompression by suboccipital craniotomy was performed.
Reports of neurologic complications, especially intracranial hemorrhage, following coronary
artery bypass surgery, arc reviewed. Possible pathophysiologic mechanisms for these prob­
lems, and the diagnosis and treatment of this previously undcscribcd complication of coro­
nary artery bypass surgery are discussed.

146

Anderson/Biller/Schrciber

orders, vasculitis or extravasation into a
hemorrhagic infarction. This report describes
the unusual, and to our knowledge, pre­
viously unreported occurrence of a cerebellar
hemorrhage in the immediate postoperative
period following coronary artery bypass sur­
gery.
Case Report
In February 1983, a 54-year-old normotensive,
diabetic male underwent aortocoronary vein graft by­
pass to the diagonal branch of the left anterior de­
scending, diagonal, obtuse marginal, ramus and right
coronary arteries. Pump time was 1 h and 40 min and
cross clamp time was 70 min. Patient’s chest tubes.
Swan Ganz catheter, arterial line and Foley catheter
were all discontinued at appropriate intervals. 3 days
postoperativcly, he noticed a mild to moderate bifrontal and occipital headache. The headache progressed,
and approximately 10 days postoperativcly he devel­
oped nausea and vomiting. In addition, he noted a
tendency to veer towards the right side on walking and
had a single episode of binocular horizontal diplopia.
A neurological consultation was then immediately re­
quested. He had no prior history of headaches, trauma
or focal neurological disturbances. Medication in­
cluded digoxin, propranolol (Indcral), aspirin, di­
pyridamole (Persantin) and tolbutamide (Orinase).

During the examination, he was awake, oriented to
place, person, time and situation, and had two 15second episodes of 40 bcats/min bradycardia. Other­
wise his vital signs were normal. He responded to
questions slowly with slight hoarseness but no dysar­
thria. He had bilateral horizontal nystagmus with the
fast component in the direction of gaze. There was a
minimal right pronator drift with slight right-sided
terminal dysmetria and appendicular ataxia. Funduscopy was normal. The remainder of the neurological
examination was unremarkable. Routine studies of
blood yielded normal results. Emergency uninfused
CT demonstrated a right cerebellar hemorrhage (fig. 1)
with displacement of the fourth ventricle and mild to
moderate temporal horn enlargement (fig. 2). Emer­
gency neurosurgical consultation was requested. After
pretreatment with mannitol (Osmitrol 20%), steroids
(Decadron), and hyperventilation, a suboccipital cra­
niotomy in the sitting position was performed. A corticotomy was made in the right cerebellar hemisphere
just lateral to the midline. This immediately revealed
approximately 30 mm of acute and subacute blood
clot which was resected. The clot was found to have
shifted vermian structures significantly across the
midline to the left. The wound was irrigated and
closed in the usual fashion. Postoperative course was
uncomplicated. Pathologic examination disclosed no
evidence of tumor or arteriovenous malformation.
Follow-up examination 12 months after surgery
showed a completely normal neurologic examina­
tion.

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Fig. 1. CT of the posterior fossa
demonstrating a high-density lesion
in the posterior aspect of the right
cerebellar hemisphere.
Fig. 2. A slightly higher CT scan
showing the superior aspect of the
lesion in figure 1, distortion and
right to left displacement of brain
stem structures, and evidence of
ventricular (temporal horn) enlarge­
ment.

Spontaneous Cerebellar Hemorrhage after Coronary Artery Bypass Surgery

Most instances of neurological dysfunc­
tion after open heart surgery result from a
combination of predisposing and operative
factors. Cerebral complications have been at­
tributed to macroembolization of air or par­
ticulate matter, microembolization of air, fat,
platelet-fibrin aggregates, foreign particles or
antifoaming agents. Other causes of brain
damage relate to inadequate cerebral perfu­
sion in patients predisposed by prior cerebro­
vascular disease, prolonged cardiopulmonary
bypass, or low perfusion pressures due to
inadequate capillary bed perfusion [1-12].
The pathologic entities usually described in­
clude focal or multifocal infarcts, emboli
lodged in small cerebral vessels, cerebral
edema and intracranial hemorrhage [5-7],
usually petechial, pcrvascular or focal in the
subarachnoid space. Intracranial hemorrhage
has been described by Humphreys et al. [5] to
occur in children who had repair of congeni­
tal heart defects. Hungxict al. [6] reported 20
cases of intracranial hemorrhage following
open heart surgery. In their series, almost all
patients were under the age of 15, and symp­
toms appeared within 24 h of surgery. Addi­
tionally, 85% of the hemorrhages occurred in
the epidural or subdural space. In only 2
cases was the hemorrhage in the brain sub­
stance or the subarachnoid space. The author
found at surgery, tearing of the superior sagit­
tal sinus in 3 cases, bleeding from parasagittal
veins in 1 case, and dural vessel oozing in 2
cases. Additionally, autopsies in 4 cases re­
vealed subarachnoid hemorrhage in 2 cases,
diffuse petechial hemorrhage in 1, and intra­
cerebral hematoma with intraventricular ex­
tension in 1. Intraoperative anticoagulation,
hypertonic perfusion, excessive diuresis, and
venous and/or arterial hypertension during

or after perfusion were postulated as poten­
tial pathogenetic mechanisms by the authors.
In our patient, no history of hypertension
could be elicited prior to, during or after cor­
onary vein graft bypass surgery, ‘pump time’
was not prolonged and no coagulation abnor­
malities were detected prior, during, or after
surgery. Symptoms progressed somewhat
slowly initially. Later, however, there was
progression of neurologic signs compatible
with brain stem compression, emphasizing
the often unpredictable course of some cere­
bellar hemorrhages. The pathogenesis of cer­
ebellar or other intracranial hemorrhages af­
ter open heart surgery is unclear, but un­
doubtedly is multifactorial and dependent on
the combined effects of anticoagulation, ve­
nous or arterial hypertension and periopera­
tive embolism.

References
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Discussion

147

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Anderson/Biller/Schreiber

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Received: May 11, 1984
Accepted: July 11, 1984
Douglas E. Anderson, MD,
Division of Neurological Service,
Loyola University,
Stritch School of Medicine,
2160 S. First Avenue,
Maywood, IL 60153 (USA)

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