Case Report: Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal Surgery for Tuberculum Sella Meningioma: A Case Report

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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." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-1118", "name": "Case Report: Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal..." } } ] } Home Browse Case Report: Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Sidabutar R, Naibaho G, Sutiono AB et al. Case Report: Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal Surgery for Tuberculum Sella Meningioma: A Case Report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1118 ( https://doi.org/10.12688/f1000research.169699.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Case Report: Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal Surgery for Tuberculum Sella Meningioma: A Case Report [version 1; peer review: 1 approved, 1 approved with reservations] Roland Sidabutar 1,2 , Guata Naibaho 1,2 , Agung Budi Sutiono 1,2 , Selfy Oswari 1,3 , Sheila Sumargo https://orcid.org/0009-0003-0764-0043 1 Roland Sidabutar 1,2 , Guata Naibaho 1,2 , [...] Agung Budi Sutiono 1,2 , Selfy Oswari 1,3 , Sheila Sumargo https://orcid.org/0009-0003-0764-0043 1 PUBLISHED 15 Oct 2025 Author details Author details 1 Neurosurgery, Universitas Padjadjaran, Bandung, West Java, Indonesia 2 Neurosurgery, Dr Hasan Sadikin Hospital, Bandung, West Java, Indonesia 3 Neurosurgery, Rumah Sakit Pusat Otak Nasional, Jakarta, Special Capital Region of Jakarta, Indonesia Roland Sidabutar Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Supervision, Writing – Review & Editing Guata Naibaho Roles: Conceptualization, Investigation, Writing – Review & Editing Agung Budi Sutiono Roles: Conceptualization, Investigation, Writing – Review & Editing Selfy Oswari Roles: Conceptualization, Formal Analysis, Investigation, Supervision, Writing – Review & Editing Sheila Sumargo Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Oncology gateway. Abstract 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. READ ALL READ LESS Keywords Case report, Tuberculum Sella Meningioma, Endoscopic Endonasal Approach, Remote Intracranial Haemorrhage Corresponding Author(s) Sheila Sumargo ( [email protected] ) Close Corresponding author: Sheila Sumargo Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Sidabutar R et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Sidabutar R, Naibaho G, Sutiono AB et al. Case Report: Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal Surgery for Tuberculum Sella Meningioma: A Case Report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1118 ( https://doi.org/10.12688/f1000research.169699.1 ) First published: 15 Oct 2025, 14 :1118 ( https://doi.org/10.12688/f1000research.169699.1 ) Latest published: 15 Oct 2025, 14 :1118 ( https://doi.org/10.12688/f1000research.169699.1 ) Introduction The endoscopic endonasal approach (EEA) has revolutionised the surgical management of anterior skull base lesions. 1 For pathologies such as pituitary adenoma and tuberculum sella meningiomas, this approach provides a direct, minimally invasive corridor that avoids the brain retraction associated with traditional transcranial methods. Despite these advantages, however, the EEA carries a unique risk profile, including cerebrospinal fluid (CSF) leakage and neurovascular injury. 2 , 3 A particularly devastating, though infrequent, complication of any neurosurgical procedure is postoperative intracranial haemorrhage. 4 While bleeding at the operative site is most common, a far rarer phenomenon is Remote Intracranial Haemorrhage (RIH), defined as bleeding anatomically distinct from the surgical bed. 5 This report details a highly unusual case of a delayed, combined supratentorial intracerebral haemorrhage (ICH) and subdural haematoma (SDH) five days after an EEA for a tuberculum sella meningioma. This specific constellation of features—a supratentorial location, a combined parenchymal and subdural pattern, and a delayed onset following a purely endonasal procedure—is exceptionally rare. Therefore, the purpose of this report is to provide a detailed account of this event, analyse the underlying pathophysiological mechanisms, and discuss the critical implications for diagnosis and management. Case report A 54-year-old female presented with a two-month history of progressively blurred vision and a right temporal hemianopia, superimposed on a two-year history of chronic headaches. Her medical history was negative for arterial hypertension, bleeding disorders or anticoagulant use. The timeline of the case presentation is shown in Figure 1 . Hormonal status was within normal limit. Preoperative magnetic resonance imaging (MRI) revealed a 1.91 × 2.01 × 1.82 cm solid, globular mass that avidly enhanced with gadolinium and showed a dural tail attached to the tuberculum sella ( Figure 2 ). She underwent a Simpson Grade I resection of the tumour via a endoscopic endonasal transsphenoidal approach ( Figure 3 ). The surgery was unremarkable and histopathology confirmed a Meningothelial Meningioma, WHO Grade I. The immediate postoperative period (days one to four) was uneventful; the patient was conscious and alert with improving vision. The patient showed minimal CSF leakage from the nostril postoperatively and some polyuria adequately manage with desmopressin tablet 0.1 mg. However, on the postoperative day five, the patient was found to be drowsy (Glasgow Coma Scale score of 13). Figure 1. Timeline of case presentation. Figure 2. Contrast Head MRI T-1 Weighted showed a 1.91 × 2.01 × 1.82 cm solid, globular mass which enhanced homogenously with gadolinium and showed a dural tail attached to the tuberculum sella. T2 weighted image showed isointense mass at tuberculum without any remarkable surrounding oedema. Figure 3. EEA was performed. A. Tuberculum on the anterior part of sellar floor was exposed and drilled. B. U shaped durotomy was performed exposing the tumor attached to the duramater. C. Tumor was being removed. Tumor was grayish red, easy to bleed with rubbery consistency and not suctionable. Detachment of tumor from surrounding sturctures. D. Neurovascular structures revealed including anterior communicating artery, Anterior cerebral artery (A1 and A2), recurrent artery of Heubner and Optic Nerve. There was no active bleeding seen after tumor removal. An emergency non-contrast head CT scan was performed immediately following the neurological decline. This revealed a remote haemorrhagic event, distant from the original operative site. The findings included a 20cc left parietal intracerebral haematoma and a concomitant acute left frontoparietal subdural haematoma. The combined mass effect resulted in a midline shift of over 5 mm ( Figure 4 ). Figure 4. Non Contrast Head CT Scan showed hyperdense lesion at right parietal lobe with volume approximately 20cc accompanied by acute subdural haemorrhage less than 10 mm thickness along left frontoparietal lobe which caused a midline shift more than 5 mm to right. Medical therapy to control intracranial pressure (ICP) was initiated, consisting of intravenous mannitol and head-of-bed elevation. Following this conservative management, her level of consciousness progressively improved over the next three days. However, the patient suddenly became aphasic and could not understand any command on day 13 th postoperatively ( Figure 5 ). Another head CT scan was performed and revealed partially resolved ICH at the parietal lobe with slight additional thickness of subacute SDH and midline shift to the right. Conservative management with mannitol and tranexamic acid was continued. The patient showed clinical improvement after 2 days and discharged from hospital at day 18 th postoperatively. The three-month postoperative MRI confirmed gross total resection of the meningioma and complete resolution of the remote haemorrhage, without evidence of any vascular malformation ( Figure 6 ). Figure 5. The non contrast head CT scan on day 13 th postoperative showed resolution of parietal lobe ICH with perifocal oedema and subacute SDH on frontoparietal lobe with more than 5 mm midline shift to the right. Figure 6. Follow up head MRI on outpatient clinic 3 months after the surgery showed no residual mass and small encephalomalacia from resolution of ICH and SDH from T1 and T2 weighted images. Discussion This case represents a rare and clinically significant variant of RIH. While haemorrhage is a known neurosurgical complication, it most often occurs at the operative site, with RIH only accounts for less than 1%. 6 RIH is a distinct entity, with the few existing reports after EEA primarily describing extradural haematomas or subdural hematoma. 7 – 10 The occurrence of a delayed, combined supratentorial ICH and SDH after an endonasal procedure is, to our knowledge, an exceptionally rare event. Consequently, a unifying mechanistic cascade provides the most compelling explanation for the findings in our case. The dominant pathophysiological theory for RIH centres on the loss of CSF volume and subsequent intracranial hypotension. The proposed sequence begins with a small, occult CSF leak from the dural repair site. This gradual egress of CSF over several days leads to intracranial hypotension, causing the brain to sag caudally (cerebral ptosis). 11 This downward displacement, in turn, exerts tractional force on the cortical bridging veins that anchor the cerebrum to the dural sinuses. Ultimately, this tension can lead to the tearing of a bridging vein, resulting in haemorrhage. 12 , 13 Several key features of this case provide strong corroborative suggestion for this CSF hypovolaemia cascade. First, the five-day delay between surgery and the haemorrhagic event is a critical temporal clue. This delayed presentation argues against inadequate intraoperative haemostasis and instead points towards a more indolent process, such as a slow CSF leak. 14 Second, the radiological finding of a combined ICH and SDH provides a clear anatomical signature for a ruptured cortical bridging vein. A tear in such a vein as it crosses the subdural space would lead to an SDH, and retrograde propagation of the tear to the pial surface would cause an associated ICH. 15 Furthermore, the patient’s transient hypertension at the time of deterioration was likely a contributing factor rather than the primary cause. In a scenario where the bridging veins were already under critical tension from cerebral ptosis, a transient surge in venous pressure could have provided the final stress needed to induce rupture. 15 The differential diagnosis also includes the haemorrhagic transformation of an ischemic infarct, a ruptured cryptic vascular malformation, and delayed cerebral vasospasm 16 ; however, the clinical and radiological findings make these alternatives highly unlikely. Ultimately, choosing non-operative management for this patient was successful and offers additional diagnostic validation. The approach to treating spontaneous intracerebral haemorrhage (ICH) continues to be debated, as studies present mixed outcomes when comparing surgical intervention to conservative treatment. 17 However, surgical management was primarily reserved for significant hematomas (>30cc) accompanied by worsening consciousness, often occurring in relatively younger patients. 18 Conservative treatment for small intracerebral haemorrhages can be effective, particularly in patients with a GCS score of 13 or higher, or with hematoma volume under 30 mL. 19 Conclusion In conclusion, delayed, remote, combined supratentorial ICH and SDH is a rare but potentially devastating complication of the EEA. The evidence presented in this case points unequivocally to a venous-origin haemorrhage, most plausibly initiated by occult CSF egress leading to intracranial hypotension and the rupture of a cortical bridging vein. This report delivers a critical message: clinicians must maintain a high index of suspicion for RIH in any patient with delayed neurological deterioration following transsphenoidal surgery. Prompt diagnosis and an understanding of the underlying venous mechanism are paramount, as this life-threatening complication can often be managed successfully with conservative therapy. Consent Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. Data availability Repository: CARE checklist for ‘Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal Surgery for Tuberculum Sella Meningioma: A Case Report’. https://doi.org/10.6084/m9.figshare.29987188 . 20 Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication). Acknowledgments None. References 1. Zoli M, Guaraldi F, Pasquini E, et al. : The Endoscopic Endonasal Management of Anterior Skull Base Meningiomas. J. Neurol. Surg. Part B. Skull Base. 2018 Oct; 79 (S 04): S300–S310. 2. Porras JL, Rowan NR, Mukherjee D: Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review. Brain Sci. 2022 Dec 8; 12 (12): 1685. PubMed Abstract | Publisher Full Text | Free Full Text 3. Akins PT, Ledgerwood LG, Duong HT: Early and late complications after open and endoscopic neurosurgery for complex skull base and craniofacial pathology: Case series, illustrative cases, and review. Interdiscip. Neurosurg. 2022 Sep; 29 : 101552. Publisher Full Text 4. Seifman MA, Lewis PM, Rosenfeld JV, et al. : Postoperative intracranial haemorrhage: a review. Neurosurg. Rev. 2011 Oct; 34 (4): 393–407. Publisher Full Text 5. Garg K, Tandon V, Sinha S, et al. : Remote site intracranial hemorrhage: Our experience and review of literature. Neurol. India. 2014; 62 (3): 296–302. PubMed Abstract | Publisher Full Text 6. Borkar SA, Lakshmiprasad G, Sharma BS, et al. : Remote site intracranial haemorrhage: a clinical series of five patients with review of literature. Br. J. Neurosurg. 2013 Dec; 27 (6): 735–738. PubMed Abstract | Publisher Full Text 7. Destiansyah RA, Savitri CMA, Wisnawa IWW, et al. : Remote extradural hematoma as a complication of endoscopic transsphenoidal surgery: A case report with literature review. Int. J. Surg. Case Rep. 2022 Jul; 96 : 107341. PubMed Abstract | Publisher Full Text | Free Full Text 8. Takeuchi K, Watanabe T, Nagatani T, et al. : Incidence and risk factors of subdural hematoma after intraoperative cerebrospinal fluid leakage during the transsphenoidal approach. Pituitary. 2016 Dec; 19 (6): 565–572. PubMed Abstract | Publisher Full Text 9. Mahmoodkhani M, Koohi N, Motamedi A, et al. : A rare but serious case of subdural hematoma following transsphenoidal surgery for a pituitary adenoma. Interdiscip. Neurosurg. 2025 Jun; 40 : 102016. Publisher Full Text 10. Noriaki F, Hiroshi N, Shozo Y: Acute subdural hematoma immediately after extended transsphenoidal surgery for craniopharyngioma. Turk. Neurosurg. 2014 [cited 2025 Aug 7]; 27 : 309–311. PubMed Abstract | Publisher Full Text 11. Senapati SB, Acharya A, Mohanty RK, et al. : The Rare Presentation of Traumatic Intracranial Hypotension: A Case Report. Asian J. Neurosurg. 2025 Jun; 20 (02): 427–430. 12. Morandi X, Haegelen C, Henaux PL, et al. : Brain shift is central to the pathogenesis of intracerebral haemorrhage remote from the site of the initial neurosurgical procedure. Med. Hypotheses. 2006 Jan; 67 (4): 856–859. PubMed Abstract | Publisher Full Text 13. Li D, Fu C, Xu D, et al. : Remote peritentorial hemorrhage complicating supratentorial aneurysmal surgery: a report of three cases and literature review. Acta Neurochir. 2013 Feb; 155 (2): 271–276. PubMed Abstract | Publisher Full Text 14. Lopez A, Hernández A, Valencia C, et al. : Subdural haematoma as a late complication of spontaneous cerebrospinal fluid hypovolemia (SCH) syndrome: Two case reports/INS. J. Neurol. Sci. 2013 Oct; 333 : e506. Publisher Full Text 15. Miller JD, Nader R: Acute subdural hematoma from bridging vein rupture: a potential mechanism for growth: Clinical article. J. Neurosurg. 2014 Jun; 120 (6): 1378–1384. PubMed Abstract | Publisher Full Text 16. Brown RJ, Kumar A, Dhar R, et al. : The Relationship Between Delayed Infarcts and Angiographic Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery. 2013 May; 72 (5): 702–708. PubMed Abstract | Publisher Full Text | Free Full Text 17. Juvela S, Heiskanen O, Poranen A, et al. : The treatment of spontaneous intracerebral hemorrhage: A prospective randomized trial of surgical and conservative treatment. J. Neurosurg. 1989 May; 70 (5): 755–758. Publisher Full Text 18. Hegde A, Menon G, Kumar V: Surgery for spontaneous intracerebral hemorrhage – A comparative study with medical management in moderate to large sized hematomas. Clin. Neurol. Neurosurg. 2019 Sep; 184 : 105415. PubMed Abstract | Publisher Full Text 19. Cho DY, Chen CC, Lee HC, et al. : Glasgow Coma Scale and hematoma volume as criteria for treatment of putaminal and thalamic intracerebral hemorrhage. Surg. Neurol. 2008 Dec; 70 (6): 628–633. PubMed Abstract | Publisher Full Text 20. Sheila S: Repository CARE checklist for ‘Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal Surgery for Tuberculum Sella Meningioma: A Case Report. figshare. Dataset. 2025. Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 15 Oct 2025 ADD YOUR COMMENT Comment Author details Author details 1 Neurosurgery, Universitas Padjadjaran, Bandung, West Java, Indonesia 2 Neurosurgery, Dr Hasan Sadikin Hospital, Bandung, West Java, Indonesia 3 Neurosurgery, Rumah Sakit Pusat Otak Nasional, Jakarta, Special Capital Region of Jakarta, Indonesia Roland Sidabutar Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Supervision, Writing – Review & Editing Guata Naibaho Roles: Conceptualization, Investigation, Writing – Review & Editing Agung Budi Sutiono Roles: Conceptualization, Investigation, Writing – Review & Editing Selfy Oswari Roles: Conceptualization, Formal Analysis, Investigation, Supervision, Writing – Review & Editing Sheila Sumargo Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 15 Oct 2025, 14:1118 https://doi.org/10.12688/f1000research.169699.1 Copyright © 2025 Sidabutar R et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Sidabutar R, Naibaho G, Sutiono AB et al. Case Report: Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal Surgery for Tuberculum Sella Meningioma: A Case Report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1118 ( https://doi.org/10.12688/f1000research.169699.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 15 Oct 2025 Views 0 Cite How to cite this report: Tandean S and Josethang A. Reviewer Report For: Case Report: Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal Surgery for Tuberculum Sella Meningioma: A Case Report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1118 ( https://doi.org/10.5256/f1000research.187057.r433803 ) The direct URL for this report is: https://f1000research.com/articles/14-1118/v1#referee-response-433803 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 24 Nov 2025 Steven Tandean , Universitas Sumatera Utara, Medan, Indonesia Alexander Josethang , Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Medan, Sumatera Utara, Indonesia Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.187057.r433803 It is a good work, the authors have tried to gather all the data from their work However several questions likely to be asked : Is there any association of the location of bleeding, in your ... Continue reading READ ALL It is a good work, the authors have tried to gather all the data from their work However several questions likely to be asked : Is there any association of the location of bleeding, in your case it is in the (L) side, why is there the problem, is there any literature or any thought why it could happen? It seems that the authors suggested that intracranial hypotension due to CSF leak as the primary cause, is there any literature review or how would the author recommend readers so that the complication can be avoided? Will it be the use of patch or minimizing the size of incision? What does this case teach us so that it won't happen again next? It seems that vit K used is 10 mg/8 hr, so it is 30 mg/24 h, would the authors clarify this dose? Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Neurosurgery, Neurovascular, Interventional, Neuroscience, Research We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Tandean S and Josethang A. Reviewer Report For: Case Report: Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal Surgery for Tuberculum Sella Meningioma: A Case Report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1118 ( https://doi.org/10.5256/f1000research.187057.r433803 ) The direct URL for this report is: https://f1000research.com/articles/14-1118/v1#referee-response-433803 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Haq IBI. Reviewer Report For: Case Report: Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal Surgery for Tuberculum Sella Meningioma: A Case Report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1118 ( https://doi.org/10.5256/f1000research.187057.r424847 ) The direct URL for this report is: https://f1000research.com/articles/14-1118/v1#referee-response-424847 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 22 Oct 2025 Irwan Barlian Immadoel Haq , Soetomo General Academic Hospital, Surabaya, Indonesia Approved VIEWS 0 https://doi.org/10.5256/f1000research.187057.r424847 Strengths: Good case report, clinically valuable. The paper highlights an extremely rare but critical complication following endoscopic endonasal approach (EEA) surgery that treat succesfully. It provides meaningful insight for clinicians, particularly in recognizing delayed postoperative neurological deterioration. ... Continue reading READ ALL Strengths: Good case report, clinically valuable. The paper highlights an extremely rare but critical complication following endoscopic endonasal approach (EEA) surgery that treat succesfully. It provides meaningful insight for clinicians, particularly in recognizing delayed postoperative neurological deterioration. Detailed clinical timeline. The chronology of the patient’s condition and clinical course is well-documented, making the case easy to follow and clinically instructive. Comprehensive investigations and long-term follow-up. Imaging was thorough, and the inclusion of a 3-month follow-up adds strength to the overall clinical outcome and reinforces the completeness of recovery. Clear explanation of the pathophysiology. The discussion provides a plausible and well-argued mechanism, linking occult CSF leak and intracranial hypotension to venous rupture and remote hemorrhage, offering valuable insights into the possible pathogenesis. Suggestions for Improvement: Highlight early recognition strategies. The report could be strengthened by offering practical recommendations for early detection (such as red flags or suggested imaging thresholds in postoperative care) Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Neurooncology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Haq IBI. Reviewer Report For: Case Report: Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal Surgery for Tuberculum Sella Meningioma: A Case Report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1118 ( https://doi.org/10.5256/f1000research.187057.r424847 ) The direct URL for this report is: https://f1000research.com/articles/14-1118/v1#referee-response-424847 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 15 Oct 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 1 15 Oct 25 read read Irwan Barlian Immadoel Haq , Soetomo General Academic Hospital, Surabaya, Indonesia Steven Tandean , Universitas Sumatera Utara, Medan, Indonesia Alexander Josethang , Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Tandean S et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 24 Nov 2025 | for Version 1 Steven Tandean , Universitas Sumatera Utara, Medan, Indonesia Alexander Josethang , Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Medan, Sumatera Utara, Indonesia 0 Views copyright © 2025 Tandean S et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions It is a good work, the authors have tried to gather all the data from their work However several questions likely to be asked : Is there any association of the location of bleeding, in your case it is in the (L) side, why is there the problem, is there any literature or any thought why it could happen? It seems that the authors suggested that intracranial hypotension due to CSF leak as the primary cause, is there any literature review or how would the author recommend readers so that the complication can be avoided? Will it be the use of patch or minimizing the size of incision? What does this case teach us so that it won't happen again next? It seems that vit K used is 10 mg/8 hr, so it is 30 mg/24 h, would the authors clarify this dose? Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Neurosurgery, Neurovascular, Interventional, Neuroscience, Research We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above. reply Respond to this report Responses (0) Tandean S and Josethang A. Peer Review Report For: Case Report: Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal Surgery for Tuberculum Sella Meningioma: A Case Report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1118 ( https://doi.org/10.5256/f1000research.187057.r433803) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1118/v1#referee-response-433803 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Haq I. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 22 Oct 2025 | for Version 1 Irwan Barlian Immadoel Haq , Soetomo General Academic Hospital, Surabaya, Indonesia 0 Views copyright © 2025 Haq I. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Strengths: Good case report, clinically valuable. The paper highlights an extremely rare but critical complication following endoscopic endonasal approach (EEA) surgery that treat succesfully. It provides meaningful insight for clinicians, particularly in recognizing delayed postoperative neurological deterioration. Detailed clinical timeline. The chronology of the patient’s condition and clinical course is well-documented, making the case easy to follow and clinically instructive. Comprehensive investigations and long-term follow-up. Imaging was thorough, and the inclusion of a 3-month follow-up adds strength to the overall clinical outcome and reinforces the completeness of recovery. Clear explanation of the pathophysiology. The discussion provides a plausible and well-argued mechanism, linking occult CSF leak and intracranial hypotension to venous rupture and remote hemorrhage, offering valuable insights into the possible pathogenesis. Suggestions for Improvement: Highlight early recognition strategies. The report could be strengthened by offering practical recommendations for early detection (such as red flags or suggested imaging thresholds in postoperative care) Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Neurooncology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Haq IBI. Peer Review Report For: Case Report: Remote Intracerebral Haemorrhage after Endoscopic Transsphenoidal Surgery for Tuberculum Sella Meningioma: A Case Report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1118 ( https://doi.org/10.5256/f1000research.187057.r424847) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1118/v1#referee-response-424847 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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