Cerebellar hemorrhage after spine fixation misdiagnosed as a complication of narcotics use -A case report-.

Abstract

Cerebellar hemorrhage occurs mainly due to hypertension. Postoperative cerebellar hemorrhage is known to be associated frequently with frontotemporal craniotomy, but quite rare with spine operation. A 56-year-old female received spinal fixation due to continuous leg tingling sensation for since two years ago. Twenty-one hours after operation, she was disoriented and unresponsive to voice. Performed computed tomography showed both cerebellar hemorrhage. An emergency decompressive craniotomy was carried out to remove the hematoma. On the basis of this case, we reported this complications and reviewed related literature.

Full text

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Korean J Anesthesiol 2011 January 60(1): 54-56
DOI: 10.4097/kjae.2011.60.1.54
Case Report
Copyright ⓒ the Korean Society of Anesthesiologists, 2011
www.ekja.org
Cerebellar hemorrhage occurs mainly due to hypertension. Postoperative cerebellar hemorrhage is known to be
associated frequently with frontotemporal craniotomy, but quite rare with spine operation. A 56-year-old female
received spinal fixation due to continuous leg tingling sensation for since two years ago. Twenty-one hours after
operation, she was disoriented and unresponsive to voice. Performed computed tomography showed both cerebellar
hemorrhage. An emergency decompressive craniotomy was carried out to remove the hematoma. On the basis of
this case, we reported this complications and reviewed related literature. (Korean J Anesthesiol 2011; 60: 54-56)
Key Words: Cerebellar hemorrhage, Cerebrospinal fluid pressure, Spine, Surgery.
Cerebellar hemorrhage after spine fixation misdiagnosed as
a complication of narcotics use
-A case report-
Ki-Hwan Yang, Jeong Uk Han, Jong-Kwon Jung, Doo Ik Lee, Sung-Il Hwang, and Hyun Kyoung Lim
Department of Anesthesiology and Pain Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, Korea
Received: July 23, 2010. Revised: September 17, 2010. Accepted: September 30, 2010.
Corresponding author: Hyun Kyoung Lim, M.D., Department of Anesthesiology and Pain Medicine, Inha University Hospital, Inha University College
of Medicine, 7-206, Sinheung-dong 3-ga, Jung-gu, Incheon 400-711, Korea. Tel: 82-32-890-3968, Fax: 82-32-881-2476, E-mail: hkliman@inha.ac.kr
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://
creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium,
provided the original work is properly cited.
CC
Cerebellar hemorrhage occurs mainly due to hypertension
[1]. Postoperative cerebellar hemorrhage, on the other hand,
is known to be frequently associated with frontotemporal
craniotomy [2], but rarely with a spine operation [3]. Minimal
cerebellar hemorrhage may be treated with medication and
close observation while severe hemorrhage should be corrected
surgically.
Postoperative mental depression may occur due to the taking
of narcotics for pain control, hypothermia, metabolic disorders
such as electrolyte imbalance, or disorders in the central nerve
system [4]. These authors report a case of cerebellar hemorrhage
after a spine fixation operation for a lower-limb tingling
sensation on a 56-year-old female, which was misdiagnosed as
a complication of narcotics use.
Case Report
A 56-year-old female was admitted to these authors’ facility
for spine fixation due to a two-year continuous lower-limb
tingling sensation. She was 153 cm tall and weighed 38 kg.
Other than hysterectomy and chemotherapy ten years earlier,
she had no underlying disease. Her PT, aPTT, and platelet count
were within the normal range. She thus showed no signs of
coagulopathy.
Under noninvasive monitoring, anesthetic induction was
carried out with intravenous injection of thiopental 200 mg
and rocuronium 30 mg, after which intubation was done. The
anesthesia was maintained with remifentanil 0.05-0.1 μg/kg/
min and sevoflurane 1-2 vol%.

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Korean J Anesthesiol
Yang, et al.
Spine fusion of the third and fourth lumbar spine was done
in the prone position, during which the systolic blood pressure,
heart rate, percutaneous oxygen saturation, and end-expiratory
carbon dioxide partial pressure were maintained at 100-120
mmHg, 60-90, 100%, and 33-37 mmHg, respectively. Her
ABGA with FiO2 at 0.5 (oxygen + room air) was pH 7.48, PCO2
38 mmHg, PO2 294 mmHg, and HCO3 25.3 mmol/L, while her
electrolytes were Na 137, K 3.1, and Cl 0.91 mEq/L.
The overall operation time was five hours. The estimated
blood loss was 800 ml, and the patient was given 400 ml RBC
transfusion, 2,200 ml crystalloid, and 500 ml colloid.
When the operation was finished, a patient-controlled
analgesic device was added to her IV line. This device con-
tinuously infused 0.5 ml drug per hour, and when she needed
more, 0.5 ml was infused every 15 minutes. The device
contained 1,000 μg fentanyl and 8 mg ondansetron, where
normal saline was added, totaling 60 ml. Overall, the device
could infuse 9-45 μg fentanyl per hour.
After the operation, the patient showed no specific neurologic
deficit. She was transferred to the recovery room under the
supervision of an anesthesiologist, where she stayed for 30
minutes, after which she was transferred to the general ward,
without any neurologic deficit.
Seventeen hours after the operation, the patient com-
plained of nausea, which was controlled with intravenous
metoclopramide 10 mg, which is known to be effective
against nausea after narcotics use. Nineteen hours after the
operation, the patient was still nauseous and lethargic, which
were thought to be complications of narcotics use. Thus, the
PCA was stopped. Until then, however, about 600 μg fentanyl
had been administered to the patient. Twenty-one hours after
the operation, the patient was disoriented and unresponsive
to voices, so computed tomography of her brain was taken,
which showed cerebellar hemorrhage (Fig. 1). Angio CT did
not demonstrate any malformation, such as aneurysm or
arteriovenous malformation.
Emergent decompressive craniotomy was carried out to
remove the hematoma. Then the patient was moved to the
surgical intensive care unit. The intracranial pressure was
0-1 mmHg. As the patient showed no improvement in terms
of lethargy, tracheostomy was performed after ten days.
Although her consciousness level returned to alert 30 days
after the operation, she still suffered ataxia and aphasia. She
was transferred to the rehabilitation department, where her
symptoms improved. She was then transferred to another
hospital for conservative management.
Discussion
Cerebellar hemorrhage after craniotomy or a spine operation
was first reported by Chadduck [5], and there have been few
reports of it since then. Despite the many opinions regarding it,
there are no definitely proven causes of cerebellar hemorrhage
from a spine operation. Hypertension, bleeding tendency, and
undiscovered cerebral aneurysm may be some of the causes.
According to Chadduck [5], increased blood pressure in-
creased the gap between the intravascular pressure and the
cere bro spinal-fluid pressure, which caused the hemorrhage
in the case he presented. Andrews and Koci [6] reported
that the hemorrhage in the case they presented was due to
reperfusion after temporary traction, entanglement, and spasm
of the superior cerebellar artery. Some authors suggested that
the position during an operation is related with cerebellar
hemorrhage, which may happen particularly when the patient
is in a sitting position or when the head is overextended,
compressing the jugular veins [7]. In the case presented herein,
however, there was no blood pressure increase, and the patient
was in a supine position, without vein compression.
Honegger et al. [8] discovered cerebellar hemorrhage via brain
CT scan in a patient who received subgaleal suction drainage
and who had no specific symptoms, suggesting that extensive
suction drainage may cause hemorrhage.
Brockmann et al. [9] reported a unique cerebellar hemorr-
hagic pattern shown in CT after an operation, assuming
cerebrospinal-fluid leakage as the most plausible explanation.
Friedman et al. [10] mentioned cerebellar hemorrhage
occurring from the temporary compression of the superior
cerebellar artery caused by the downward migration of the
cerebellum after cerebrospinal-fluid leakage.
Suction drainage was performed in the case presented
herein; 890 ml body fluid was drained on the first day, which
Fig. 1. Brain computed tomographic image shows cerebellar hemo-
rrhage within vermis.

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Cerebellar hemorrhage after spinal fusion
Vol. 60, No. 1, January 2011
was stopped when the patient showed neurologic symptoms.
Considering that the drained fluid was serosanginous,
cerebrospinal-fluid leakage cannot be ruled out, which
coincides with Friedman et al.’s mention [10] of cerebellar
migration and hemorrhage.
Cerebrospinal-fluid leakage indicates dura mater tearing.
Kuslich et al. [11] reported dura mater tearing in 3-10% of the
cases after spinal fixation, while Chen et al. [12] reported 3.4%.
Scintigraphy is the definite diagnostic method for dura mater
tearing, which was not taken in the case presented herein. Thus,
cerebrospinal-fluid leakage due to dura mater tearing could not
be confirmed.
Nowadays, postoperative pain control is often performed
with the use of patient-controlled analgesic devices. Narcotics
use may result in respiratory depression, nausea and vomiting,
urinary difficulty, pruritus, and sedation [13]. Although
sedation rarely occurs, as neurological signs can be overlooked,
narcotics use is usually avoided when neurological evaluation
is required after surgery. Dolin and Cashman [13] reported
that 25.2% of the patients in his study suffered from nausea,
and 20.2% from vomiting, after the use of narcotics. Dolin and
Cashman [13] also reported mild sedation after intravenous
patient-controlled analgesic device use in 56.5% of the patients,
and severe sedation in 5.3%. Ready et al. [14] suggested that
severe sedation may be an early symptom of respiratory
depression. The symptoms in this case were also misinterpreted
as side effects of patient-controlled analgesic device. When
postoperative patients become lethargic, various causes should
be considered, such as cerebellar hemorrhage in the case
presented herein.
Brockmann and Groden [4] reported that symptoms were
apparent within 10 hours in 46% of postoperative cerebellar-
hemorrhage cases, 10-20 hours in 17%, 20-30 hours in 17%,
30-40 hours in 3%, and after 40 hours in 17%. In the case
presented herein, the symptoms were manifested 17 hours after
the operation.
In the case presented herein, the patient, who did not
manifest any specific problem from the surgery or anesthesia,
showed nausea and lethargy the day after the operation,
regarded as complications of fentanyl administration. Despite
the discontinuation of fentanyl administration, however,
her symptoms were aggravated. Cerebellar hemorrhage was
eventually diagnosed via emergency CT scan.
When a patient’s consciousness, respiration, and muscle tone
recover fully from anesthesia and lethargy develops, or when
there is no improvement of the lethargy after discontinuing
the narcotics use, other problems besides the side effects
of narcotics use should be considered, which may cause
neurological deficit. Cerebellar hemorrhage after a spine
operation may be rare, but it should always be considered for
prompt diagnosis and treatment, to prevent severe neurologic
complications.
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