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Supratentorial intracerebral haemorrhage following posterior fossa operation
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     1 Department of Neurosurgery, Sel?uk University, Faculty of Meram Medicine, Turkey

    2 Kocatepe University, Faculty of Medicine, Turkey

    A 63-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 dysmetri and bilaterally papiledema. CT scan also revealed a calcified 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 have 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 hemiplejia 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 [Figure - 4].

    Discussion

    The literature on supratentorial intracerebral hemorrhage following posterior fossa surgery is rare. Heines et al reported 5 supratentorial hemorrhages after posterior fossa operation in 825 patients firstly. The patients had neither coagulopathy nor predisposant factors.[1],[2] Harder et al l presented 3 supratentorial intracerebral hemorrhage in 187 posterior fossa surgery.[3] The mechanism of intracerebral hemorrhage after posterior fossa surgery is unclear. Harder et al have suggested that the surgery in sitting position may decrease intraserebral arterial blood flow, causing cerebral ischemia. As soon as the patient puts back in normal position after surgery hyperperfusion leads to intraserebral hematoma in ischemic brain tissue.[3]

    Changes in intracranial dynamics in the sitting position are known to produce subdural hematomas by disruption of cortical bridging veins. By the same mechanism, subcortical veins might be torn and cause intracerebral bleeding.[2]

    Cartier-Giroux J, suggested that the removing of tumor may have irritative effects on vasomotor area in medulla, causes sudden increase in arterial pressure consequently massive basal ganglia bled. Otherwise, it may be related with rapid release of longstanding elevated intracerebral pressure by posterior fossa surgery in the sitting position with loss of CSF, with consecutive tearing on the ependymal ventricular walls.[4] Impaired blood coagulation after meningioma surgery is well known.[2],[5]

    Our patient underwent an operation in sitting position with ventricular drainage for relief of increased intracranial pressure. In both preoperative and postoperative period her coagulation parameters were normal. Mean arterial pressure values coursed at normal ranges throughout the operation and pre and postoperative periods also. In our case the remote hematoma has occurred in right deep parietal and frontal region it may be derived from tearing of subependymal or basal ganglia perforating veins. The neurological detoriation after 6 hours surgery supports this probability.

    Conclusion

    Supratentorial intracerebral hemorrhage following posterior fossa surgery is scanty and this pathology should be suspected in patients who develop new neurological deficit and detailed neurological examination in the early postoperative period is the best way to identify supratentorial pathology by CT scanning and may be vital.

    References

    1. Haines SJ, Maroon JC, Jannetta PJ. Supratentorial intracerebral hemorrhage following posterior fossa surgery. J Neurosurg 1978;49:881-6.

    2. Tondon A, Mahapatra AK. Superatentorial intracerebral hemorrhage following infratentorial surgery. J Clin Neurosci 2004;11:762-5.

    3. Harders A, Gilsbach J, Weigel K. Supratentorial space occupying lesions following infratentorial surgery: Early diagnosis and treatment. Acta Neurochir Wien 1985;74:57-60.

    4. Cartier-Giroux J, Mohr G, Sautreaux JL. Supratentorial hemorrhage of hypertensive origin during operation: an unusual complication of surgery on the posterior fossa in the sitting position. Neurochirurgie 1980;26:291-4.

    5. Brisman MH, Bederson JB, Sen CN, Germano IM, Moore F, Post KD. Intracerebral haemorrhage occurring remote from the craniotomy site. Neurosurgery 1996;39:1114-21.(Kalkan Erdal, Eser Olcay)