Cerebellar haemorrhage and tension pneumocephalus after resection of a Pancoast tumour

Abstract

We present an unusual case of cerebellar haemorrhage followed by tension pneumocephalus several days after thoracotomy for resection of a Pancoast tumour. The postoperative course of the 32-year-old patient was complicated by a cerebellar haemorrhage and hydrocephalus caused by compression of the fourth ventricle. Immediate surgical evacuation of the haemorrhage and placement of an external ventricular drain was performed. Respirator ventilation maintaining a continuous positive airway pressure was required. Following weaning and extubation the patient rapidly deteriorated and became comatose. A cranial CT scan revealed a dilated ventricular system filled with air, and air in the subarachnoid space. Recovery of consciousness was observed after aspiration of intracranial air through the ventricular drainage. Recurrent deterioration of consciousness after repeated air aspiration indicated rapid refilling of the ventricles with air.The patient underwent emergency surgical re-exploration of the thoracic resection cavity: dural lacerations of the cervico-thoracic nerve roots C8 and Th1 were identified. Subarachnoid-pleural fistula, cerebellar haemorrhage and tension pneumocephalus after discontinuation of continuous positive airway pressure respiration are unusual complications of thoracic surgery. We discuss the putative pathomechanisms and present a brief review of the literature.

Intracranial hypotension with a sixth cranial nerve palsy subsequent to massive thoracic CSF hygroma: a rare complication of thoracic disc excision

“…The mechanism of this injury is postulated as downward cerebral displacement, subsequent to CSF loss and intracerebral hypotension. This results in tension and occlusion of the superior cerebellar bridging veins, which is thought to result in venous infarction and haemorrhage [21,22]. A review of the literature reveals only five cases of confirmed remote subdural haemorrhage subsequent to spinal surgery [16].…”

Intracranial hemorrhage following lumbar spine surgery

“…Cerebellar ''sag'' which is a result of excessive CSF leakage has been proposed to cause stretching and occlusion of the superior vermian veins. In patients with insufficient venous collaterals, this may cause venous infarction, subsequently leading to hemorrhagic transformation [2,[6][7][8][9][10][11][12][13][14][15] as occurred in our first and second cases. Another explanation is a rise in transmural venous pressure associated with CSF drainage and intracranial hypotension [2].…”

“…Another explanation is a rise in transmural venous pressure associated with CSF drainage and intracranial hypotension [2]. According to the experience with RCH after spinal surgery to date (30 cases), it appears that this type of hemorrhage can occur after any type of spinal surgery, in which large-volume CSF loss has occurred during or after surgery, regardless of body positioning [2,[6][7][8][9][10][11][12][13][14][15]. RCH should be suspected in any patient with unexplained deterioration of consciousness or with delayed emergence from anesthesia following spine surgery complicated by dural tear and CSF leak [2,[6][7][8][9][10][11][12][13][14][15].…”

“…According to the experience with RCH after spinal surgery to date (30 cases), it appears that this type of hemorrhage can occur after any type of spinal surgery, in which large-volume CSF loss has occurred during or after surgery, regardless of body positioning [2,[6][7][8][9][10][11][12][13][14][15]. RCH should be suspected in any patient with unexplained deterioration of consciousness or with delayed emergence from anesthesia following spine surgery complicated by dural tear and CSF leak [2,[6][7][8][9][10][11][12][13][14][15]. The clinical presentation ranges from transient cerebellar and brainstem dysfunction to large hematoma causing obstructive hydrocephalus [2,[6][7][8][9][10][11][12][13][14][15].…”

“…RCH should be suspected in any patient with unexplained deterioration of consciousness or with delayed emergence from anesthesia following spine surgery complicated by dural tear and CSF leak [2,[6][7][8][9][10][11][12][13][14][15]. The clinical presentation ranges from transient cerebellar and brainstem dysfunction to large hematoma causing obstructive hydrocephalus [2,[6][7][8][9][10][11][12][13][14][15]. The presence of the zebra sign, bilateral cerebellar involvement, and documented CSF hypotension can help define the diagnosis and avoid unnecessary workup [6,12,13].…”