Chapter 14-7: Cerebellar Hemorrhage

TEXTBOOK PRESENTATION

The textbook presentation of cerebellar hemorrhage is the abrupt onset of headache associated with vomiting, ataxia, and vertigo. Brainstem compression may produce weakness, cranial nerve abnormalities, coma, and death. Patients with cerebellar infarctions have similar symptoms.

DISEASE HIGHLIGHTS

1. Cerebellar hemorrhage accounts for 5–16% cases of intracerebral hemorrhages.

2. Cerebellar hemorrhage is a neurologic emergency due to the potential for hematoma expansion, herniation, and death. Rapid progression within minutes to hours is common.

   1. 28–38% of patients demonstrate an increase in the hematoma on repeat CT scan within 3 hours of onset.

   2. Hematoma expansion is associated with a 5-fold increase in poor outcomes and death.

   3. Both hematoma expansion and edema contribute to an increase in intracranial pressure and brainstem herniation.

3. Etiologies

   1. Most common:

      1. Hypertensive hemorrhage

      2. Subarachnoid hemorrhage

      3. Amyloid angiopathy

      4. Arteriovenous malformations

   2. Less common:

      1. Blood dyscrasias

      2. Hemorrhagic infarction

      3. Septic emboli

      4. Anticoagulant and thrombolytic therapy

      5. Neoplasms

      6. Herpes simplex virus encephalitis

      7. Vasculitis

      8. Cocaine and amphetamine use

4. Demographics

   1. Mean age is 61–73 years

   2. 36% have diabetes mellitus

   3. 32–73% have hypertension

   4. 14% have a coagulopathy

   5. Frequency: Asians > Blacks > Hispanics > Whites

5. Complications

   1. Hydrocephalus (48%)

   2. Chronic disability

   3. Herniation and death (42%)

   4. Other: Pneumonia, myocardial infarction, and ventricular arrhythmias

6. Poor prognostic factors include

   1. Marked hydrocephalus

   2. Deteriorating consciousness

   3. Stupor and coma (100% mortality without surgery)

   4. Fever (correlates with ventricular extension of bleeding)

EVIDENCE-BASED DIAGNOSIS

1. Clinical findings

   1. The most common clinical symptoms are headache, vomiting, and altered consciousness (Table 14-10).

   2. Brainstem findings were universal in 1 study.

   3. Vertigo is present in 59% of patients.

2. Laboratory evaluation should include complete blood count, platelet count, INR, partial thromboplastin time, basic metabolic panel, ECG, chest radiograph, glucose, and toxicology screen in young- and middle-aged patients.

3. Prompt cross-sectional imaging with CT or MRI is critical to identify hemorrhage.

4. Patients with cerebellar hemorrhage due to aneurysms or arteriovenous malformation may require additional imaging and interventions.

   1. Consider if there is a low likelihood that the hemorrhage was secondary to hypertension and in patients with subarachnoid hemorrhage.

   2. Risk factors for vascular abnormalities include patients < 65 years old, cocaine use, female sex, nonsmoker, absence of a history of hypertension or coagulopathy.

   3. Aneurysms can be identified with CTA, contrast-enhanced CT, contrast-enhanced MRI, or MRA.

   4. Abnormal results can be evaluated with cerebral angiography.

TREATMENT

1. Cerebellar hemorrhages can compress vital brainstem structures and surgical evacuation can be lifesaving.

2. Emergent surgical removal of the hemorrhage is recommended for patients with large hemorrhages (> 3 cm), those with neurologic deterioration, brainstem compression, or hydrocephalus from ventricular obstruction.

3. ICU monitoring is critical.

4. Anticoagulants and antiplatelet therapy should be ...