17Moscote-Salazar_Remote Romanian Neurosurgery (2014) XXI 3: 349 - 352 349 Remote supratentorial hemorrhage after posterior fossa surgery: A brief case report Luis Rafael Moscote-Salazar1, Gabriel Alcalá-Cerra1, Hernando Raphael Alvis-Miranda2, Omar Ramírez3, Willem Guillermo Calderón-Miranda4, Andrés M. Rubiano5 1Neurosurgeon, Universidad de Cartagena, Colombia 2Physician, Universidad de Cartagena, Colombia 3Neurosurgeon, Universidad El Bosque, Colombia 4Physician, Universidad del Magdalena, Colombia 5Neurosurgeon, Hospital Universitario de Neiva, Colombia Abstract The supratentorial hemorrhage after posterior fossa surgery is an unusual but delicate complication that carries high mortality and morbidity. A 50 year old woman presented vertigo 6 months of evolution, which worsened in the last 2 months accompanied by ataxia. She showed left cerebellar signs, had no focal motor or sensory deficits. A brain MRI identified cerebellopontine angle lesion with mass effect. The patient was treated on suboccipital craniectomy and resection of right posterior fossa tumor, the histopathological diagnosis was consistent with typical meningioma. (WHO Class I). The postoperative period was satisfactory. A month later, presented clinical symptoms of right-sided hemiparesis, brain CT revealed left frontal supratentorial hematoma, receiving conservative management. Patient was discharged after 10 days. Reports in the literature on this rare complication, detailed cases where the hematoma was presented in hours to days. To our knowledge this is the first report in the literature of supratentorial hemorrhage and posterior fossa surgery one month after the surgical procedure has been performed. Key words: Meningioma, posterior fossa surgery, supratentorial hemorrhage, Neurosurgery Introduction Remote supratentorial hematoma after posterior fossa surgery for the removal of a space-occupying lesion is a rare but dramatic and dreaded complication, carrying significant morbidity and mortality. We describe a rare complication of extensive supratentorial hemorrhage following posterior fossa surgery; review the relevant 350 Moscote-Salazar et al Remote supratentorial hemorrhage after posterior fossa surgery literature and discus the possible cause of hemorrhage in the present case. Case report A 50-year-old woman had a history of headache and progressive ataxia over 1 year. Neurological examination showed a horizontal nystagmus, a slight gait ataxia, right dysmetria and bilaterally papilledema. CT scan also revealed a right meningioma of 6x5x5,5 cm in size in the right posterior fossa with moderate hydrocephalus (Figure 1). Preoperative right carotid and right vertebral artery angiographic scan has been done. The patient underwent suboccipital craniectomy in sitting position and ventricular drainage has been performed to prevent air embolism. So intraoperative course was uneventful and tumor removed totally [Figure - 2]. In early postoperative neurological examination was normal but after six hours she became somnolent and developed a hemiplegia on the left site. A new CT scan revealed a hyperdense lesion of 2x1,5x4 cm in size in the right fronto- parietal region [Figure - 3]. The patient was treated conservatively and the patient's neurologic state improved in five days. CT scan revealed a hypodense lesion in the right fronto-parietal region in subsequent second month. Discusion Supratentorial intracerebral hemorrhage is uncommon after posterior fossa surgery. Figures 1 and 2 - Preoperative brain T1W MRI contrast images showing large posterior fossa tumor on right side with mass effect Figure 3 - Postoperative CT scan revealed a hyperdense lesion of 2x1,5x4 The mechanism for producing the bleeding is not entirely certain, but it is proposed that in the case where the sitting position is used, a Romanian Neurosurgery (2014) XXI 3: 349 - 352 351 decrease of cerebral blood flow and then cerebral ischemia occurs. By switching the position after surgery hyperperfusion areas leads to bleeding in ischemic areas. Heines et al reported 5 supratentorial hemorrhages after posterior fossa surgery in 825 patients firstly. The patients had neither coagulopathy nor predisposant factors. [1,2] TABLE 1 Summary of published supratentorial intracerebral hemorrhage after posterior fossa surgery Author and year Age/Gender Diagnosis Localization POP interval Sequela Haines, 1978 65/F 55/F 41/F 64/F 62/F Neuralgia V right Neuralgia IX right Neuralgia V right An. painful right Schwanoma VIII left Right Occipital Ringht basal ganglia Right Frontoparietal Left frontal Intraventricular 4 hrs 45 min inmediate 18 horas Inmediate -- Standefer, 1984 59/-- Meningioma Basal ganglia 7 days -- Harders, 1985 44/F 51/F 58/M Meningioma Schwnoma VIII Meningioma Left frontoparietal Bilateral frontal Left parietal -- -- -- -- Seiler, 1986 66/F 64/F 59/F Schwnoma VIII Right Right meningioma Right Schwnoma Right Parietal Left parietal Right occipital Inmediate 3 hrs 24 hrs -- Kalfas, 1988 -- -- -- -- -- Bucciero, 1991 46/F Hemangioblastoma Left Temporoparietal 6 hrs -- Prieto, 1993 45/F Left Schwnoma VIII Left Frontoparietal 16 hrs -- Tondon, 2004 30/F 50/F schwannomas Astrocitoma Left Parietaloccipital Basal ganglia 24 hrs 6 hrs Died Died Kalkan, 2006 63/F Meningioma -- 6 hrs -- Agrawal, 2010 47/F --- Right Temporal 3 hrs -- Moscote, 2014 50/F Meningioma Left frontal 30 days Right hemiparesis F: female M: male Our patient underwent tumor resection in the benck park position. No ventricular drain was placed. In the preoperative and postoperative periods coagulation parameters were normal. The values of blood pressure preoperatively, intraoperatively and postoperatively were normal. Bleeding was probably caused by the rupture of perforating veins of the basal ganglia or in the subependymal region. 352 Moscote-Salazar et al Remote supratentorial hemorrhage after posterior fossa surgery Conclusion The supratentorial hemorrhage after posterior fossa surgery is an unusual but delicate complication that carries high mortality and morbidity. Reports in the literature on this rare complication, evidence cases where the hematoma was presented in hours to days. (3, 4, 5, 6, 7, 8, 9, 10). To our knowledge this is the first report in the literature of supratentorial hemorrhage and posterior fossa surgery one month after the surgical procedure has been performed. Correspondence Dr. Luis Rafael Moscote-Salazar, Universidad de Cartagena, Cartagena de Indias, Colombia, e-mail: mineurocirujano@aol.com References 1. Tondon A, Mahapatra AK. Superatentorial intracerebral hemorrhage following infratentorial surgery. J Clin Neurosci. 2004;11:762–5. [PubMed] 2. Haines SJ, Maroon JC, Jannetta PJ. Supratentorial intracerebral hemorrhage following posterior fossa surgery. J Neurosurg. 1978;49:881–6. [PubMed] 3.Kalkan E, Eser O. Supratentorial intracerebral haemorrhage following posterior fossa operation. Neurol India. 2006;54:220–1. 4. Bucciero A, Quaglietta P, Vizioli L. Supratentorial intracerebral hemorrhage after posterior fossa surgery: Case report. J Neurosurg Sci. 1991;35:221–4. [PubMed] 5. Harders A, Gilsbach J, Weigel K. Supratentorial space occupying lesions following infratentorial surgery early diagnosis and treatment. Acta Neurochir (Wien) 1985;74:57–60. [PubMed] 6. 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