Remote cerebellar hemorrhage due to ventriculoperitoneal shunt in an infant: a case report

Abstract

Introduction: Cerebellar hemorrhage remote from the operative site is an unpredictable and rare complication in neurosurgery, with reported rates of morbidity and mortality in the literature of 8.4% and 7.8%, respectively. The range of procedures associated with remote cerebellar hemorrhage is diverse and includes both supratentorial and spinal procedures that entail significant cerebral spinal fluid loss or resection of supratentorial content. We present here the first documented case of remote cerebellar hemorrhage after controlled supratentorial cerebral spinal fluid drainage by ventriculoperitoneal shunt, and discuss the proposed pathophysiology and treatment.

Case presentation: We present the case of a four-month-old Saudi Arabian male baby who presented with progressive symptoms and signs of congenital hydrocephalus. An uneventful ventriculoperitoneal shunting was performed with our patient recovering smoothly in the immediate postoperative period. On the next day, he had frequent episodes of vomiting and became lethargic. An urgent computed tomography scan of his brain revealed mild ventricular decompression and unexpected cerebellar hemorrhage. The infant was put under close observation, with marked spontaneous improvement over 48 hours and complete resolution of the hemorrhage on a follow-up computed tomography brain scan two weeks later. On regular outpatient visits at one, three and twelve months, he had no neurological deficit.

Conclusion: Remote cerebellar hemorrhage is a complication that remains enigmatic in terms of both the underlying mechanism and clinical behavior. Our case revealed that the risk factors identified in the literature are not sufficient in predicting patients at risk of developing remote cerebellar hemorrhage. Our report also adds to the growing body of evidence challenging the currently accepted hypothesis explaining the pathomechanism of remote cerebellar hemorrhage. It thereby remains an unpredictable hazard that requires further study and increased awareness, as many cases in the literature are incidental findings.

Figure 1

Sagittal T1-weighted magnetic resonance image demonstrating obstructive hydrocephalus due to congenital aqueductal stenosis.

Figure 2

Sagittal T1-weighted magnetic resonance image four weeks after the endoscopic third ventriculostomy. Demonstrates unchanged ventricular size despite patent ventriculostomy

Figure 3

Sagittal computed tomography scan demonstrating the extent of the subcortical and intraparenchymal cerebellar hemorrhage. Note the classic zebra sign.

Figure 4

Coronal computed tomography scan demonstrating bilateral cerebellar hemorrhages.

Figure 5

Axial computed tomography scan demonstrating bilateral acute cerebellar hemorrhage.

Figure 6

Axial computed tomography scan revealing no supratentorial intraparenchymal or intraventricular hemorrhage related to the catheter insertion.