Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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June 13, 2019
Remote supratentorial Hemorrhage
- Background
- Remote postoperative hemorrhage is a known complication of spinal surgeries and occurs typically in the subdural space and the tentorial surface of the cerebellum.
- Only a few cases of remote supratentorial hemorrhage have been described.
- Clinical Presentation
- The range of clinical presentations varies widely, from dramatic thunderclap headaches, often positional in nature, to subtle focal neurological deficits like cerebellar dysfunction. Altered mental status and seizures have also been reported.
- Key Diagnostic Features
- Bilateral symmetrical subdural hematomas or hygromas, accompanied by hematomas in the cerebellum or superficial lobar regions. Rarer locations of hemorrhage include the convexal subarachnoid space.
- The predisposition of bleeding for areas like the cerebellum is postulated to be the result of stretching and occlusion of bridging intracranial veins, caused by the downward shift of the brain when a large volume of cerebrospinal fluid (CSF) is rapidly lost, resulting in hemorrhagic venous infarcts. Likewise, supratentorial bridging veins can be compromised in a similar manner.
- Other features or complications of intracranial hypotension may be seen, such as pachymeningeal enhancement, pituitary gland engorgement, diffuse cerebral edema, brainstem sagging or drooping of the splenium of the corpus callosum, and even cerebral venous thrombosis. These may not be as frequently present in postoperative neurosurgical cases with dural breach, as the CSF loss may be too acute and large for these compensatory changes to occur.
- Differential Diagnosis
- The differentials for multi-compartmental hemorrhages are limited, and the presence of coagulopathies must be sought. They may also be seen in the setting of hematological malignancies like leukemia, but patients usually present subacutely and are more unwell and drowsy. Contrast enhancement is typically seen in the leptomeninges, pachymeninges, along cranial nerves and rarely, in mass-like parenchymal lesions. Cerebral infarction can occur due to venous sinus thrombosis, as patients are in a hypercoagulable state.
- Subdural hematomas are most often caused by trauma with damage to the bridging veins that traverse the subdural space.
- Convexal subarachnoid hemorrhages are seen in reversible cerebral vasoconstriction syndrome (RCVS) and cerebral amyloid angiopathy (CAA). In RCVS, vasoconstriction results in a beaded appearance of medium-to-large cerebral arteries on imaging. Clues to the diagnosis of CAA include the presence of lobar hematomas, cerebral microhemorrhages in the cortico-subcortical junction and cortical superficial siderosis.
- Treatment
- Treatment may be conservative, as most dural tears will seal spontaneously with time, but dural repair may be undertaken in cases with progressive or severe neurological deficits.
- There is no gold standard imaging modality for the detection of leakage site in spinal CSF leak.
- Radioisotope cisternography has comparable sensitivity to CT cisternography, but poorer anatomical resolution. MR myelography may be an effective non-invasive alternative, with CSF leak appearing as CSF space expansion around nerve root sleeves with accompanying irregular high signal intensity along the sleeves.
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