CONTRALATERAL CEREBELLAR HEMORRHAGIC INFARCTION AFTER PTERIONAL CRANIOTOMY - REPORT OF 5 CASES AND REVIEW OF THE LITERATURE

OBJECTIVE AND IMPORTANCE: Five cases of cerebellar hemorrhagic infarct ion complicating pterional craniotomy are presented. Recognition of th is rare complication may be delayed, with catastrophic consequences, b ecause clinicians are unaware of the possibility. We suggest that the mechanism of this complication is dislocation of the dependent part of the cerebellum and venous obstruction causing hemorrhagic infarction. CLINICAL PRESENTATION: Five patients undergoing pterional craniotomie s for benign conditions (four unruptured aneurysms and one meningioma) developed hemorrhagic infarction of the contralateral cerebellum in t he postoperative period. This resulted in obstructive hydrocephalus an d brain stem compression. A review of the literature revealed only one previous report of a similar complication in patients with gross coag ulopathy. This was not a problem in our patients.INTERVENTION: The tim e of onset of symptoms varied from immediately postoperative to 24 hou rs later. Once the diagnosis was made, the hydrocephalus was drained a nd the posterior fossa was decompressed. CONCLUSION: The outcome depen ded on two variables: 1) the rate of development of hemorrhagic infarc tion and the associated complications and 2) the amount of time that e lapsed before remedial action was taken. Two patients with the first s igns of deterioration in the immediate postoperative period had the wo rst outcome; one died and the other remained severely disabled. In two patients with good neurological recovery, problems were identified an d corrected within 4 hours of the first sign of deterioration. Rapid o verdrainage of cerebrospinal fluid during supratentorial surgery shoul d be avoided, and the fluid volume should be replaced before closure. Postoperative evaluation of patients whose conditions deteriorate afte r supratentorial craniotomy should include adequate imaging studies of the posterior fossa.