Intracranial Hemorrhage A Rare Complication Secondary to Cerebrospinal Fluid Leak Post Spine Surgery
Naser HajAissa1, Divya Patel3, Maulik Kantawala2
1Neurology, 2Cerebral Vasc/Stroke, Corewell Health West, Michigan State University, 3Corewell Health West, Michigan State University
Objective:

Remote cerebellar hemorrhage (RCH) and other intracranial hemorrhages are rare but potentially serious complications of spinal surgery associated with cerebrospinal fluid (CSF) loss. This report aims to highlight the clinical significance, underlying mechanisms, and the importance of early recognition and postoperative monitoring in patients with intraoperative durotomy or high-volume CSF drainage.

Background:

A 61-year-old woman with hypertension, atrial fibrillation (on Eliquis, held five days preoperatively), and prior L5–S1 fusion underwent revision instrumentation and decompression from L3–S1. The procedure was complicated by dense adhesions requiring extensive dissection and an unintended durotomy. A Jackson-Pratt (JP) drain collected approximately 800 mL of CSF in 24 hours. On postoperative day one, she developed severe headache, nausea, vomiting, and right upper extremity ataxia, prompting a stroke code. Imaging revealed a right cerebellar intraparenchymal hemorrhage with minimal edema and pneumocephalus. MRI demonstrated diffuse dural enhancement and findings consistent with intracranial hypotension. There was no evidence of trauma, hypertension, coagulopathy, or venous thrombosis. The drain was removed on postoperative day two.

Design/Methods:

Case report and literature review 

Results:
RCH and other intracranial hemorrhages following spinal surgery are uncommon but serious complications linked to excessive CSF loss. Proposed mechanisms involve downward cerebellar sag due to intracranial hypotension, resulting in stretching and tearing of cerebellar bridging veins, venous infarction, and hemorrhage. Literature reviews by Di et al., Farag et al., and Khalatbari et al. highlight that such events may occur even after minimally invasive procedures and in the absence of hypertension or coagulopathy. Clinical manifestations range from headache to focal deficits, often delayed or masked by postoperative sedation and analgesia. Awareness, early neuroimaging, and careful management of CSF drainage are crucial for preventing morbidity and optimizing recovery. 
Conclusions:
NA
10.1212/WNL.0000000000215096
Disclaimer: Abstracts were not reviewed by Neurology® and do not reflect the views of Neurology® editors or staff.