Remote cerebellar hemorrhage after supratentorial craniotomy: illustrative cases

BACKGROUND: Remote cerebellar hemorrhage (RCH) is an extremely rare and potentially fatal complication after supratentorial craniotomy. However, the exact pathophysiological mechanism of RCH remains unclear, so clinicians often lack clinical experience in prevention, early diagnosis, and standardized treatment. OBSERVATIONS: The authors retrospectively analyzed data of patients who underwent surgery for supratentorial lesions at their center between 2012 and 2021. They identified 4 patients who developed RCH among 4,075 patients who underwent supratentorial craniotomy. All 4 patients were male, with an average age of 57.5 years. One RCH occurred after tumor resection, and the other 3 occurred after aneurysm clipping. One patient was asymptomatic and received conservative treatment with a favorable outcome. The remaining 3 patients underwent lateral ventricular drainage and/or suboccipital decompression; 2 died, and 1 recovered well. LESSONS: The authors believe that RCH should be considered as a multifactorial cause, and massive cerebrospinal fluid loss plays a key role in the development and progression of RCH. Asymptomatic RCH can be treated conservatively. However, in the case of conscious disturbance, hydrocephalus, and brain stem compression, surgery should be performed immediately. Early detection and individualized treatment would be helpful to avoid potentially fatal outcomes caused by RCH.