postoperative remote intracranial hemorrhage has the same risk factors as nontraumatic intracranial bleeding : hypertension , coagulopathy , anticoagulant therapy , and vascular disorders . remote intracranial hemorrhage , particularly cerebellar hemorrhage after spine surgery , has been well - documented in the literature . however , concomitant supra- and infra - tentorial intra - parenchymal hemorrhage after spine surgery is very rare , since 7 cases were reported in the literature . we present a 57-year - old female with intracranial multiple hemorrhages after spine surgery and we discuss diagnosis , patho - mechanism , and treatment approaches with a review of the relevant data in the literature . a 57-year - old female presented with intractable low back pain and severely impaired mobility . one year ago , she underwent lumbar laminectomy and fusion with posterior spinal instrumentation between l2 and s1 . her motor strength was 4/5 in her lower limbs , and she had decreased sensation in bilateral dermatomes from l1 to s1 . she developed adjacent segment disease at the upper level of the instrumented vertebra [ figure 1a ] . then , she had a revision surgery of posterior laminectomies ( t11-l1 ) and posterior spinal fusion with bilateral transpedicular instrumentation from t10 to s1 [ figure 1b ] . . lateral spinal x - ray after revision surgery ( b ) postoperative neurological examination and laboratory values were within normal limits . however , she had severe headache , somnolence , and left hemiparesia 48 h after the surgery . her emergent head computed tomography revealed intraprenchymal hemorrhage in the right parietal lobe accompanying with subarachnoid hemorrhage , bilateral symmetrical cerebellar hemorrhages and pneumocephalus [ figure 2 ] . the hemovac drain was removed and the drain exit site was closed with a single suture . the patient was admitted to intensive care unit and managed nonsurgically . however , her cognitive impairment , residual dysphagia , and neurogenic bladder were still present . intra - parenchymal hemorrhages in right parietal lobe and bilateral cerebellum accompanied with pneumocephalus and subarachnoid hemorrhage over - drainage of cerebrospinal fluid ( csf ) resulting in remote cerebellar hemorrhage ( rch ) has been well - documented in the literature . rch is associated with cranial and less with spinal surgeries ( 100 vs. 15 cases in the literature ) . however , concomitant supra- and infra - tentorial intra - parenchymal hemorrhage after spine surgery is very rare ; only 7 cases were reported in the literature [ table 1 ] . female : male ratio is 6:2 and the median age is 52.5 years ( range = 28 - 69 years ) for patients with concomitant supra- and infra - tentorial intra - parenchymal hemorrhage after spine surgery . these patients underwent spinal surgery for spondylopathic myelopathy , spinal canal stenosis , intervertebral disc herniation , failed back surgery , chordoma , and intradural extramedullary spinal tumor . signs and symptoms for the intra - parenchymal hemorrhage were headache , nausea , seizure , hemiparesia , delayed arousal from anesthesia , impaired consciousness , dysarthria , dysphasia , lethargy , hypotonia , dysmetria , adiodochokinesia , and dilated nonreactive pupils . concomitant supra - and infra - tentorial intra - parenchymal hemorrhages after spine surgery in the literature one of the theories for intracranial hemorrhage after csf leakage in spine surgery suggests that intra - luminal pressure in vessels increases and ruptures the vessels . the second theory suggests that the inferior displacement of cerebellum causes the entrapment of venous sinuses between the cerebellum and skull base . , the third one suggests that massive loss of csf causes acute occlusion of the intracranial bridging veins . in a postmortem case study , cornips et al . massive loss of csf has been considered a risk factor for more devastating intracranial hemorrhage . in 8 patients with concomitant supra- and infra - tentorial hemorrhage after spine surgeries , 2 patients underwent spinal dural repair and 6 patients two patients died of brain herniation and 1 patient died of aspiration pneumonia and sepsis . symptoms including constant headache , nausea , vomiting , impaired consciousness , new onset seizure and focal neurological deficit after spine surgeries should raise the suspicion of intracranial intra - parenchymal hemorrhage . intracranial intra - parenchymal hemorrhage should be evaluated neuro - radiologically to determine the severity and to treat patient surgically or nonsurgically in a timely manner . was supported by a grant from tubitak ( the scientific and technological research council of turkey ) , grant number : 1059b191400255 . murat akir eki , m.d . was supported by a grant from tubitak ( the scientific and technological research council of turkey ) , grant number : 1059b191400255 .
remote cerebellar hemorrhage after cranial and spinal surgeries is a well - documented entity , so far concomitant supra- and infra - tentorial hemorrhage after spine surgery has rarely been reported in the literature . a 57-year - old woman presented with intractable low back pain and severely impaired mobility . 
 one year ago , she underwent lumbar laminectomy and fusion with posterior spinal instrumentation between l2 and s1 . 
 she developed adjacent segment disease at the upper level of the instrumented vertebra . 
 she had a revision surgery and underwent posterior laminectomy and fusion with bilateral transpedicular instrumentation between t10 and s1 . 
 she had severe headache , somnolence , and left hemiparesia 48 h after the surgery . 
 her emergent head computed tomography depicted intra - parenchymal hemorrhage in the right parietal lobe accompanying with subarachnoid hemorrhage , bilateral symmetrical cerebellar hemorrhages and pneumocephalus . 
 she was treated nonsurgically and she got better despite some residual deficits . 
 symptoms including constant headache , nausea , vomiting , impaired consciousness , new onset seizure , and focal neurological deficit after spine surgeries should raise suspicion for intracranial intra - parenchymal hemorrhage .