Article
Supra- and infratentorial hemorrhage as a consequence of loss of cerebrospinal fluid after surgery – two case reports
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Published: | September 16, 2010 |
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Objective: Illustration of two rare cases with supra- and infratentorial hemorrhage as a consequence of an accelerated loss of cerebrospinal fluid.
Methods: Both pts. were admitted to our hospital for neurosurgical intervention. One pat. (88 yrs., female, case 1) suffered from a right-sided space-occupying chronic subdural hematoma (cSDH), the other from degenerative spondylolisthesis (74 yrs., female, case 2). Clinical history, radiological and surgical interventions are demonstrated and the possible pathophysiological mechanism presented.
Results: In the first case the subdural drainage accidentally disconnected day 2 after evacuation of cSDH and loss of CSF occured. Pat. developed within hrs. a neurological deterioration with aphasia and loss of consciousness. CCT scan showed a hydrocephalus and subarachnoid hemorrhage (SAH) over both cerebellar hemispheres. An external ventricular drainage was inserted and pat. was dismissed to rehabilitation with ataxia, dysarthria and spatial orientation. In the second case primary surgery with PLIF and dorsal instrumentation was uneventful. Immediately post surgery the pat. developed uncommon blood loss over the wound drainages and arterial hypotension. CT's of abdomen/lumbar spine excluded any vascular lesions or misplacement of the implants. CCT scan showed atypical frontal intracerebral hemorrhages, a severe SAH and a generalized brain edema, especially involving the infratentorial space. A CSF leakage could not be ruled out since the drainage fluid looked suspiciously light in time course. Acute operative revision confirmed an unrecognized CSF leakage which was repaired. The pat. additionally received an external ventricular drainage Pat. received long term ICU treatment and was dismissed for rehabilitation with GOS of 3.
Conclusions: Acute loss of CSF generates a differential force on CSF which may influence the venous drainage. The velocity of CSF loss and the differential force may be proportional related. In rare conditions this may lead to intracerebral hemorrhage mainly in posterior fossa / cerebellum and to venous SAH.