Repository CARE checklist for ‘Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal Surgery for Tuberculum Sella Meningioma: A Case Report’

This case report describes an exceedingly rare complication of endoscopic endonasal approach (EEA) surgery. We reported a delayed remote combined supratentorial intracerebral and subdural haemorrhage following the resection of a tuberculum sella meningioma. This report aims to analyse the pathophysiology and discuss the management of this critical complication, which is seldom documented in the literature. We present the case of a 54-year-old female with a WHO Grade I tuberculum sella meningioma. She underwent a complete (Simpson Grade I) resection via an endoscopic endonasal transsphenoidal approach. Her initial postoperative recovery was unremarkable for four days. On the fifth postoperative day, the patient experienced an acute decline in consciousness. An emergency non-contrast head computed tomography (CT) scan revealed a remote left parietal intracerebral haemorrhage (ICH) of approximately 20cc, associated with an acute left frontoparietal subdural haematoma (SDH), causing a significant midline shift. Despite the severity of the radiological findings, the patient was managed successfully with non-operative medical therapy. She made a full clinical recovery, and a three-month follow-up magnetic resonance imaging (MRI) confirmed complete resolution of the haematomas with no evidence of residual tumour or underlying vascular malformation. The clinical timeline and radiological pattern strongly suggest a venous aetiology. The most plausible mechanism is a cascade initiated by an occult cerebrospinal fluid (CSF) leak, leading to intracranial hypotension, cerebral ptosis, and the subsequent rupture of a cortical bridging vein. This case underscores the need for a high index of suspicion for remote intracranial haemorrhage (RIH) in any patient with delayed neurological deterioration after transsphenoidal surgery. Furthermore, it demonstrates that this life-threatening complication can often be managed successfully with conservative therapy.