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Neuroradiology Case of the Week
Case 414
June 2009
Gurshawn Singh, MS2, and
Rajiv Mangla, MD
Clinical
Presentation: Patient is a 33-year-old female with history of minor trauma and subarachnoid hemorrhage.
Imaging Findings: CT angiography showed a small aneurysm in the pericallosal artery which was confirmed on catheter angiography (Fig. 1). The cerebellum was normal on pre-surgery scans (Fig. 2). Patient underwent clipping of the aneurysm. In the immediate post-op period, the patient's condition deteriorated and CT showed hemorrhage in the left cerebellar hemisphere suggestive of remote cerebellar hemorrhage.
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Figure 1: Catheter angiography showing small pericallosal artery aneurysm
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Figure 2: Pre-operative CT showing normal posterior fossa.
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| Figure 3: Axial CT immediately after supratentorial craniotomy for clipping of a pericallosal artery aneurysm shows a small area of bleed in the left cerebellar hemisphere.
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Diagnosis: Remote cerebellar hemorrhage
Discussion: Remote cerebellar hemorrhage is a rare complication of supratentorial craniotomies. Usually, they occur after supratentorial surgical procedures such as aneurysm clipping, temporal lobectomy, tumor resection, and hematoma evacuation.
The hemorrhage is remote from the surgical area and results from occlusion or rupture of superior cerebellar bridging veins. There is CSF hypovolemia responsible for the pressure changes of the veins resulting in hemorrhagic venous infarction, which is the most probable explanation for the remote cerebellar hemorrhage. Knowing about this condition can obviate the need for further unnecessary investigations. It can be mistaken for coagulopathy, hemorrhagic infarction, or cortical vein occlusion because they are more common entities. The most common presentation is decreased consciousness along with other complaints like motor deficits and gait ataxia.
The cause of this condition is unknown but many cases are found to be associated with preoperative use of anticoagulation and perioperative hypertension. This is usually a self-limiting condition which is managed conservatively. Depending on the magnitude of the bleed, intervention can be evaluated. Larger bleeds may cause mass effects resulting in hydrocephalus. In such cases, surgery is required.
References:
- Friedman JA, Piepgras DG, Duke DA, et al. Remote cerebellar hemorrhage after supratentorial surgery. Neurosurgery. 2001 Dec;49(6):1327-40. [PubMed]
- Amini A, Osborn AG, McCall TD, Couldwell WT. Remote cerebellar hemorrhage. AJNR Am J Neuroradiol. 2006 Feb;27(2):387-90. [PubMed]
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