History

Onset of cerebellar hemorrhage (CH) symptoms is generally abrupt.

Presentation varies greatly, depending on the size and location of the hemorrhage. Some patients are alert with headache and perhaps vomiting; others may be unresponsive with impaired or absent brainstem reflexes.

The following symptoms are roughly in descending order of incidence:

Headache of abrupt onset
Nausea and vomiting
Inability to walk (reflecting truncal ataxia)
Dizziness, vertigo
Dysarthria
Nuchal pain
Loss or alteration of consciousness

Physical

Physical examination findings in cerebellar hemorrhage (CH) are variable. Some patients are alert and cooperative, while others are in a coma.

Signs generally are of abrupt onset and may change suddenly with progressive expansion of hematoma.

Signs tend to cluster with level of consciousness.

Diminished level of consciousness (uncooperative to comatose)
- Irregular respirations
- Extensor plantar responses
- Impaired oculocephalic responses and a variety of other abnormal eye movements
- Decreased or absent corneal responses
- Impaired or absent pupillary responses
Lateralizing cerebellar signs may be present in a patient who is alert enough to cooperate with examination.
- Limb ataxia
- Dysarthria
- Possible presence of extensor plantar responses (unilateral or bilateral)
- Nuchal rigidity
- Nystagmus
- Gaze palsy (ipsilateral to hematoma)
- Facial weakness
Gait difficulty in patients able to cooperate is a nonspecific finding.
Noncardiac or neurogenic cardiopulmonary complications may include findings of pulmonary edema, hypertension, bradycardia, and arrhythmia.^[7]

Causes

Causes of cerebellar hemorrhage (CH) are similar to those of other types of intracranial hemorrhage. Approximately two thirds of cerebellar CHs are believed to be hypertensive hemorrhages.

Hypertension - Suspected rupture of small penetrating vessels
Amyloid angiopathy^[8]
Anticoagulant use
Blood dyscrasias
Aneurysm/arteriovenous malformation rupture
Sympathomimetic drug use
Hemorrhage into tumor
Dural leak or large CSF removal associated with supratentorial surgery, spinal surgery, or spontaneous intracranial hypotension.^[9]
CADASIL^[1]

Complications

Progression of the hemorrhage with brainstem compression and/or destruction is the most serious complication.

Differential Diagnoses

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Graffagnino C, Bergese S, Love J, Schneider D, Lazaridis C, LaPointe M, et al. Clevidipine rapidly and safely reduces blood pressure in acute intracerebral hemorrhage: the ACCELERATE trial. Cerebrovasc Dis. 2013. 36 (3):173-80. [QxMD MEDLINE Link].
Witsch J, Neugebauer H, Zweckberger K, Jüttler E. Primary cerebellar haemorrhage: complications, treatment and outcome. Clin Neurol Neurosurg. 2013 Jul. 115(7):863-9. [QxMD MEDLINE Link].
Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015 Jul. 46 (7):2032-60. [QxMD MEDLINE Link].
Amar AP. Controversies in the neurosurgical management of cerebellar hemorrhage and infarction. Neurosurg Focus. 2012 Apr. 32(4):E1. [QxMD MEDLINE Link].
[Guideline] Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007 Jun. 38(6):2001-23. [QxMD MEDLINE Link].
[Guideline] Morgenstern LB, Hemphill JC 3rd, Anderson C, Becker K, Broderick JP, Connolly ES Jr, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010 Sep. 41(9):2108-29. [QxMD MEDLINE Link].
Khattar NK, Fortuny EM, Wessell AP, John KD, Bak E, Adams SW, et al. Minimally Invasive Surgery for Spontaneous Cerebellar Hemorrhage: A Multicenter Study. World Neurosurg. 2019 Sep. 129:e35-e39. [QxMD MEDLINE Link].
Li L, Liu H, Luo J, Tan Z, Gao J, Wang P, et al. Comparison of Long-Term Outcomes of Endoscopic and Minimally Invasive Catheter Evacuation for the Treatment of Spontaneous Cerebellar Hemorrhage. Transl Stroke Res. 2021 Feb. 12 (1):57-64. [QxMD MEDLINE Link].
Javed K, Hamad MK, Holland R, Fortunel AN, Ammar A, Cezayirli PC, et al. Use of the Image Guided Minimally Invasive BrainPath System to Evacuate Spontaneous Cerebellar Hemorrhages. Cureus. 2021 Jul. 13 (7):e16124. [QxMD MEDLINE Link].
St Louis EK, Wijdicks EF, Li H. Predicting neurologic deterioration in patients with cerebellar hematomas. Neurology. 1998 Nov. 51(5):1364-9. [QxMD MEDLINE Link].
Mohadjer M, Eggert R, May J, Mayfrank L. CT-guided stereotactic fibrinolysis of spontaneous and hypertensive cerebellar hemorrhage: long-term results. J Neurosurg. 1990 Aug. 73(2):217-22. [QxMD MEDLINE Link].
Yamamoto T, Nakao Y, Mori K. Endoscopic hematoma evacuation for hypertensive cerebellar hemorrhage. Minim Invasive Neurosurg. 2006 Jun. 49(3):173-8. [QxMD MEDLINE Link].
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Media Gallery

Large hemorrhage of cerebellar vermis.
MRI demonstrating right cerebellar hemorrhage.

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Author

Sonal Mehta, MD Advanced Neuroscience Network Physicians, Steward Medical Group

Sonal Mehta, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Stroke Association, Neurocritical Care Society, Society of Vascular and Interventional Neurology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center

Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Neurological Association, American Society of Neurorehabilitation, American Academy of Neurology, American Heart Association, American Medical Association, National Stroke Association, Phi Beta Kappa, Tennessee Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2; Physician Advisory Board for Coherex Medical; National Leader and Steering Committee Clinical Trial, Bristol Myers Squibb; Abbott Laboratories, advisory group.

Additional Contributors

Draga Jichici, MD, FRCPC, FAHA Associate Clinical Professor, Division of Medicine, Department of Critical Care Medicine and Neurology, Co-Director, Neurosurgical Intensive Care Unit, Co-Director, Transcranial Doppler Ultrasound, Hamilton Health Sciences, McMaster University School of Medicine, Canada

Draga Jichici, MD, FRCPC, FAHA is a member of the following medical societies: American Academy of Neurology, Canadian Critical Care Society, Canadian Medical Protective Association, Canadian Neurocritical Care Society, Canadian Neurological Sciences Federation, Neurocritical Care Society, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

J Stephen Huff, MD, FACEP Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD, FACEP is a member of the following medical societies: American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.