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Table of Contents    
Year : 2012  |  Volume : 60  |  Issue : 4  |  Page : 419-422

Brainstem hemorrhage following clipping of anterior communicating aneurysm: Is lumbar drain responsible?

Department of Neurosurgery, NIMHANS, Bangalore, Karnataka, India

Date of Submission20-Jun-2012
Date of Decision04-Jul-2012
Date of Acceptance25-Jul-2012
Date of Web Publication6-Sep-2012

Correspondence Address:
Paritosh Pandey
Department of Neurosurgery, NIMHANS, Bangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.100707

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 » Abstract 

Remote brainstem hemorrhage is an extremely rare complication following supratentorial surgery. We describe here a 55-year-old patient with ruptured anterior communicating artery aneurysm, who underwent an uneventful clipping of the aneurysm, and had a lumbar drainage intra-operatively to facilitate brain relaxation. In the postoperative period, he developed pontomesencephalic hemorrhage, and had a fatal outcome. The potential causative factors are discussed, and the relevant literature reviewed. This is probably the first reported case of this complication in the literature.

Keywords: Brainstem hemorrhage, CSF overdrainage, lumbar drain

How to cite this article:
Kakati A, Shukla D, Mahadevan A, Pandey P. Brainstem hemorrhage following clipping of anterior communicating aneurysm: Is lumbar drain responsible?. Neurol India 2012;60:419-22

How to cite this URL:
Kakati A, Shukla D, Mahadevan A, Pandey P. Brainstem hemorrhage following clipping of anterior communicating aneurysm: Is lumbar drain responsible?. Neurol India [serial online] 2012 [cited 2023 Mar 21];60:419-22. Available from: https://www.neurologyindia.com/text.asp?2012/60/4/419/100707

 » Introduction Top

Remote infratentorial hematoma is an extremely rare complication following supratentorial surgery. The most frequent infratentorial hematoma described following supratentorial surgery, including aneurysm surgery, is remote cerebellar hemorrhage (RCH). [1],[2] However, brainstem hemorrhage has not been described following surgery for anterior circulation aneurysms except for one report of this complication following evacuation of frontal intracerebral hematoma. [3] We describe a patient who developed brainstem hemorrhage following surgery for ruptured anterior communicating artery aneurysm and lumbar drainage intra-operatively to facilitate brain relaxation.

 » Case Report Top

A 55-year old-male presented with a sudden onset of severe headache and vomiting of 4-day duration. He was drowsy but arousable and had neck stiffness and Kerning's sign with no focal neurological deficits. A cranial computed tomography (CT) scan revealed diffuse subarachnoid hemorrhage (SAH), with blood in anterior interhemispheric fissure and suprasellar cisterns, and bilateral lateral ventricles (Fisher grade 3). Four-vessel digital subtraction angiography (DSA) revealed an anterior communicating artery aneurysm measuring 7 × 5 × 4 mm with a neck of 4 mm, filling predominantly from the left internal carotid artery (ICA), and left A 1 segment was filling the bilateral A 2 segment and also the aneurysm. The right A 1 segment was hypoplastic [Figure 1].
Figure 1: (a) Preoperative CT scan of head showing diffuse SAH; (b) preoperative CT scan of head showing normal brainstem, without any hematoma; (c) DSA left ICA injection oblique views showing anterior communicating artery aneurysm; (d) DSA left vertebral artery injection showing the absence of any vascular malformation in the brainstem

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He was taken up for left pterional craniotomy and clipping of the aneurysm. Preoperatively, the lumbar drain was placed to facilitate brain relaxation, and a controlled release of cerebrospinal fluid (CSF) was performed. Great care was taken to prevent sudden decompression and the drain was placed 5 cm above the head level. Aneurysm was clipped without any technical complications. Total temporary clipping time was 5 min. Total CSF drained during surgery was 60 cc. Hemodynamics were quite stable during the entire intra-operative period. Postoperatively, the patient remained altered and was localizing to painful stimuli and was moving all the four limbs equally. He was electively ventilated and shifted to the ICU. Cranial CT done within 6 h of surgery showed clip artifacts in the region of the anterior communicating artery with no infarct in the anterior cerebral artery territory and a hematoma in the pontomesencephalic junction in the midline along with the effacement of the basal cisterns. After seeing the brainstem hematoma, the lumbar drain was removed and the patient was continued on ventilation and ICU management. A repeat CT scan performed 2 days postsurgery revealed enlargement and organization of the brainstem hematoma [Figure 2]. The patient had a downhill course, with his neurological state deteriorating; he had Glasgow coma scale score 3 on the sixth postoperative day and he died on the eighth postoperative day. An autopsy confined to the examination of brain only was done 18 h after death, with informed consent from close relatives. A well-clipped anterior communicating aneurysm, turned upward and left surrounded by subarachnoid hemorrhage was noted. The right A 1 segment was hypoplastic and the A 2 segment on both sides was patent, and there was no evidence of infarct in the A 2 territory. The horizontal sectioning of the brain stem and cerebellum revealed linear acute hemorrhage in the midline along the pontomesencephalic junction extending bilaterally, in addition to distinct hemorrhages noted along the lateral margin. These were thought to be representing Duret's hemorrhages secondary to downward and lateral herniation leading to the rupture of paramedian and long circumferential perforating vessels along the pontomesencephalic junction and upper pons. The lower pons and medulla oblongata were normal, with no evidence of hemorrhage [Figure 3]a-c.
Figure 2: (a) Postoperative CT scan of head showing hematoma in pons; (b) postoperative CT scan done on day 3 showing extension and enlargement of hematoma; (c) effacement of basal cisterns; and (d) squashing of ventricles suggestive of herniation

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Figure 3: (a) Circle of Willis dissected out shows ACOM aneurysm with the clip in situ (arrow); (b) section through the midbrain shows large linear Duret's hemorrhage in the midline. Hematoma is also seen laterally placed caused by tearing of circumferential vessels. (c) At the level of the pons, the hemorrhage is seen dissecting through transverse pontine fibers and extending dorsally up to the ventricular ependymal

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 » Discussion Top

Lumbar drainage has been extensively used in a variety of neurosurgical procedures, including clipping of ruptured intracranial aneurysms to facilitate brain relaxation and minimize retraction. Many studies have documented the safety of the procedure. It has been observed that perioperative lumbar drain placement does not increase the risk of aneurysm rerupture or of other complications. [4] In addition, there are reports of a significant reduction in the incidence of vasospasm with lumbar drains, as they facilitate washout of the cisternal blood. [5] Recently, a randomized controlled trial, Lumbar Drainage of Cerebrospinal Fluid after Aneurysmal Subarachnoid Hemorrhage: A Prospective, Randomized, Controlled Trial (LUMAS), concluded that the lumbar drainage of CSF reduced the incidence of delayed ischemic neurological deficits significantly, and improved the early outcome. [6] However, rarely complications are associated with the placement of lumbar drains, both intra-operatively as well as during therapeutic procedures.

Cerebellar and brainstem herniation have been previously described following a lumbar drainage. Komotar et al.[7] analyzed 220 consecutive patients with subarachnoid hemorrhage, 137 of whom underwent clipping of aneurysm. Brain sag was diagnosed when there were clinical signs of transtentorial herniation; cranial CT scans showed effacement of basal cisterns with oblong brainstem. Improvement in symptoms was seen after the placement of the patient in the Trendelenburg position. Brain sag was diagnosed in 11 of the 137 (8%) patients, and most of the patients developed symptoms typically 2-4 days following surgery. Ten patients developed pupillary asymmetry, while one patient developed extensor posturing. None of the patients, however, developed brainstem or cerebellar hemorrhage. Samadani et al.[8] reported a series of 75 consecutive surgeries requiring intra-operative lumbar drainage. Two patients had a transient neurological complication, which improved following the lumbar epidural patch. One patient had multiple brainstem infarcts and cranial neuropathy due to intra-operative downward herniation. Bloch et al.[9] reported a patient who underwent lumbar drainage to prevent CSF leak after the frontal sinus was opened following pterional craniotomy for clipping of aneurysm. Three days following the removal of the drain, the patient became lethargic and obtunded due to the downward herniation of the cerebellum and brainstem. He improved after the placement of the lumbar epidural patch and his placement in the Trendlenburg position. Other authors have reported cerebellar hemorrhage, supratentorial hemorrhage, and intracerebral hematoma following lumbar drainage. [10] However, brainstem hemorrhage has not been reported following lumbar drain placement.

Infratentorial hematoma following supratentorial surgery, including aneurysm clipping, with remote cerebellar hematoma being the commonest form of infratentorial hematoma has been documented. Figueiredo et al.[2] reported three patients with remote cerebellar hemorrhage following clipping of the anterior communicating artery aneurysm without the placement of the lumbar drain. Two of the patients had good outcomes, while the third patient died of hematoma. They hypothesized that CSF overdrainage during surgery, including opening of the lamina terminalis resulted in stretching of cerebellar veins and caused cerebellar hemorrhage. They also discussed the role of head extension and subsequent jugular venous compression caused by the transverse process of  Atlas More Details in causing this complication. Brockmann et al.[1] described "zebra sign," the radiological appearance of blood over the cerebellar folia, which is seen in patients having RCH following supratentorial surgery. This patient had pontomesencephalic hematoma and not cerebellar hematoma. We hypothesize that in this patient, there probably had brainstem herniation secondary to raised intracranial pressure (ICP) following SAH, as well as drainage of CSF with intraoperative lumbar drainage. This would have resulted in the rupture of perforating vessels of the brainstem, resulting in brainstem hematoma. The patient had a recent onset raised ICP secondary to SAH, and had a high-pressure gradient between cranial and spinal compartments, which was accentuated with the placement of lumbar drain. Though the lumbar drain was removed after noticing brainstem hemorrhage on the postoperative CT scan, the patient did not improve and had a fatal outcome. This is the most severe form of brainstem herniation following an intra-operative lumbar drain described in the literature. However, this remains a hypothesis, and other reasons of brainstem hematoma could be there, similar to the pathogenesis of remote cerebellar hematoma following supratentorial surgery.

In conclusion, complications related to cerebellar and brainstem sagging should be kept in mind while opting to insert an intra-operative lumbar drain, especially in patients with SAH. Though intraoperative lumbar drains are usually safe, they can be associated with life-threatening CSF overdrainage, brainstem herniation, and hematoma.

 » References Top

1.Brockmann MA, Nowak G, Reusche E, Russlies M, Petersen D. Zebra sign: Cerebellar bleeding pattern characteristic of cerebrospinal fluid loss. Case report J Neurosurg 2005;102:1159-62.  Back to cited text no. 1
2.Figueiredo EG, de Amorim RL, Teixeira MJ. Remote cerebellar hemorrhage (zebra sign) in vascular neurosurgery: Pathophysiological insights. Neurol Med Chir (Tokyo). 2009;49:229-33; discussion 233-4.  Back to cited text no. 2
3.Türeyen K. Pontine hemorrhage after frontal craniotomy. Report of a case. J Neurosurg Sci 2002;46:85-7; discussion 87-8.  Back to cited text no. 3
4.Hellingman CA, van den Bergh WM, Beijer IS, van Dijk GW, Algra A, van Gijn J, et al. Risk of rebleeding after treatment of acute hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Stroke 2007;38:96-9.  Back to cited text no. 4
5.Klimo P Jr, Kestle JR, MacDonald JD, Schmidt RH. Marked reduction of cerebral vasospasm with lumbar drainage of cerebrospinal fluid after subarachnoid hemorrhage. J Neurosurg 2004;100:215-4.  Back to cited text no. 5
6.Al-Tamimi YZ, Bhargava D, Feltbower RG, Hall G, Goddard AJ, Quinn AC, et al. Lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage: A prospective, randomized, controlled trial (LUMAS). Stroke 2012;43:677-82.  Back to cited text no. 6
7.Komotar RJ, Mocco J, Ransom ER, Mack WJ, Zacharia BE, Wilson DA, et al. Herniation secondary to critical postcraniotomy cerebrospinal fluid hypovolemia. Neurosurgery 2005;57:286-92; discussion 286-92.  Back to cited text no. 7
8.Samadani U, Huang JH, Baranov D, Zager EL, Grady MS. Intracranial hypotension after intraoperative lumbar cerebrospinal fluid drainage. Neurosurgery 2003;52:148-51; discussion 151-2.  Back to cited text no. 8
9.Bloch J, Regli L. Brain stem and cerebellar dysfunction after lumbar spinal fluid drainage: Case report. J Neurol Neurosurg Psychiatry 2003;74:992-4.  Back to cited text no. 9
10.Schievink WI, Palestrant D, Maya MM, Rappard G. Spontaneous spinal cerebrospinal fluid leak as a cause of coma after craniotomy for clipping of an unruptured intracranial aneurysm. J Neurosurg 2009;110:521-4.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]

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