# November 2021

- Link: https://isnr.in/november-2021/
- Published: 2021-11-01T13:34:38+05:30
- Author: ISNR

## November 2021

## **CASE HISTORY**

INTERESTING CASE OF DELAYED AWAKENING FROM ANAESTHESIA POST SUPRATENTORIAL SURGERY

**Case history**

•An elderly woman presented with complaints of progressive diminution of vision 
in both eyes.

•MRI showed suprasellar meningioma impinging on the optic chiasm.

•Patient underwent excision of the mass .

•Post operatively the patient did not wake up from anaesthesia.

•CT scan was ordered to look for post-operative complications. • •

**Case contributed by –**

1.Dr Keerthinarayan M,

2.Dr.Vandana Peruri,

3.Dr.Hashim ,

4.Dr.Subodh,

5.Dr.Mythri,

Department of Radiology and Imaging ; Apollo Hospital, Sheshadripuram, Bengaluru.

| ⌊Case of the month Nov⌉ | ⌊Case of the month Nov⌉ | 
| ⌊Case of the month Nov⌉ | ⌊Case of the month Nov⌉ |

Fig. 1

| ⌊Case of the month Nov 2021⌉ | ⌊Case of the month Nov 2021⌉ | ⌊Case of the month Nov 2021⌉ |

Fig. 2

Immediate check  CT head (Plain)

DIAGNOSIS?

|  | [](https://isnr.in/wp-content/uploads/2021/11/Nov_result_2.jpg) | 
| [](https://isnr.in/wp-content/uploads/2021/11/Nov_result_3.jpg) | [](https://isnr.in/wp-content/uploads/2021/11/Nov_result_4.jpg) |

A well defined T1 iso,T2 mildly hyperintense lesion showing intense contrast enhancement
is seen in the suprasellar cistern encasing bilateral cavernous ICA and impinging
optic chiasma and prechiasmatic segment of bilateral optic nerves.

| [](https://isnr.in/wp-content/uploads/2021/11/Nov_result_5.jpg) | [](https://isnr.in/wp-content/uploads/2021/11/Nov_result_6.jpg) | [](https://isnr.in/wp-content/uploads/2021/11/Nov_result_7.jpg) |

**Images of CT scan of brain axial(a),sagittal (b)and coronal (c) sections show 
hyperdense blood layering  the subarachnoid spaces  along the cerebellar folia (
pointed by arrows).**

## **Remote cerebellar hemorrhage**

| **“Zebra sign” - Layering of blood along the **
**cerebellar folia** |  |

**Remote cerebellar hemorrhage(RCH) **is a rare but benign complication of the supratentorial
and spine surgeries^( 1). It is called remote as the hemorrhage occurs distant from
the site of surgery.

Most patients are asymptomatic. Other symptoms are of RCH are decreased level of
consciousness, motor deficits, gait ataxia, and prolonged awakening from anesthesia
as in our case^( 1). Many risk factors have been associated with RCH such as hypertension,
epilepsy, compromised coagulation status, excess CSF loss during and after surgery
and old age^(2).

Mechanism of occurrence is not well understood however the following hypotheses 
are proposed:

(a). Supratentorial procedures that involve opening of cisterns or ventricular systems
with patients in a supine position may lead to opening of cisterns and the ventricular
system causing CSF hypovolemia resulting in cerebellar sagging. This may cause transient
occlusion of  superior bridging veins of the posterior fossa leading to subsequent
hemorrhagic infarction^(1,2).

(b). In contrast, some have theorized that increased pressure gradients across veins
generated after removal of space occupying lesions such as tumors may lead to RCH
^( 3).

**REFERENCES**

1. Amini A, Osborn AG, Mccall TD et-al. Remote cerebellar hemorrhage. Americal  
Journal of Neuroradiology. 2006;27 (2): 387-90.

2. Omer A, Engelman E, Bath K, Krauthamer A, Pisinski L. Remote cerebellar hemorrhage:
A case report. Radiology Case Reports. 2019;14(3):385-389.

3.  Konig A., Laas R., Herrmann H.D. Cerebellar haemorrhage as a complication after
supratentorial craniotomy. _Acta__ __Neurochirurgica__. _1987;88(3-4):104–108