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.

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.

Case report and literature review