Case Diagnosis: Acute cerebellar hemorrhage following elective bifrontal craniotomy for pericallosal aneurysm clipping in a 68-year-old man with a history of intracranial aneurysms, paroxysmal A-fib, and prior left basal ganglia hemorrhage
Case Description: A 68-year-old male presented for elective bifrontal craniotomy and right A2-A3 pericallosal aneurysm clipping. His procedure utilized peri-operative lumbar drain placement and intracranial Brainlab navigation, with no documented intraoperative complications. Postoperatively, the patient had altered mental status. A head CT showed bilateral fronto-temporal SAH and left cerebellar hemorrhage of unclear etiology. No venous thrombus was seen on CT venogram. Work up including INR and thromboelastography was inconsistent with coagulopathy. The cerebellar bleed was managed with intravenous antihypertensives and corticosteroids. His acute hospital course was complicated by status epilepticus, MRSA pneumonia, paroxysmal sympathetic hyperactivity, and unsuccessful extubation trials. The patient was discharged to acute inpatient rehabilitation 51 days after admission, where he continued to show functional and cognitive improvements with therapies, sleep optimization, and neurostimulant initiation. His functional deficits were primarily due to cerebellar ataxia and executive function impairment. He was eventually discharged home after 19 days of acute inpatient rehabilitation.
Remote cerebellar hemorrhage is a rare, infratentorial complication which may occur after supratentorial surgery. Intracranial hypotension and coagulation disorders are possible risk factors, but the patient had none of these. Postoperative suction drainage and intraoperative CSF loss could also result in parenchymal shifts or changes in trans-tentorial pressure gradients, contributing to spontaneous hemorrhage. Despite a prolonged stay in the Neuromedicine ICU, this patient was discharged home, requiring only minimum to contact guard level of functional assistance.
Remote cerebellar hemorrhage is a rare, but significant, complication of a supratentorial intracranial aneurysm clipping. Acute inpatient rehabilitation plays an essential role in achieving improved functional outcomes in these patients.