Intracerebral hemorrhage after cranioplasty: an unpredictable treacherous complication due to reperfusion or possible systemic inflammatory response syndrome

Introduction: In case of malignant cerebral infarction and progressive neurological worsening, decompressive craniectomy is the surgical option that is recommended when medical therapies fail. The occurrence of an intracerebral hemorrhage after reconstruction of the bone defect is extremely rare. This is an extremely rare complication, with only four cases reported thus far in the literature. Case Report: A 54-year-old male suffered a malignant cerebral infarction and progressive neurological worsening requiring decompressive hemicraniectomy. Three months later, an autologous cranioplasty was performed. Postoperatively, the patient experienced a generalized epileptic seizure and a hemorrhage in the left cerebellar hemisphere on control CT scan. After surgical removal the patient did not improve, and CT revealed the occurrence of further cerebellar, mesencephalic, and intraventricular hemorrhages. Systemic inflammatory response syndrome was suspected, but death occurred 72 hours after cranioplasty. Conclusions: The reperfusion-hyperperfusion mechanism after cranioplasty might favor intracerebral hemorrhages limited to the ischemic tissue, which is unable to support the cerebral blood perfusion pressure. When diffuse atypical hemorrhages far from the surgical site occur after cranioplasty, a systemic inflammatory response syndrome is supposed.