Cerebellar Hemorrhage 

Updated: Dec 05, 2016
Author: Sonal Mehta, MD; Chief Editor: Helmi L Lutsep, MD 

Overview

Background

Advances in neuroimaging have led to revision of treatment concepts for cerebellar hemorrhage (CH). In the pre–computed tomography (CT) era, patients with large hematomas (which were detected by angiography or at postmortem examination) were overrepresented in clinical series. Surgical therapy was stressed. With the availability of cranial CT, patients with milder symptoms and smaller hematomas are increasingly detected. Nonsurgical management has been found to be effective in some of these patients. Management recommendations are still being optimized to improve outcomes.

Pathophysiology

CHs result from the same causes as other intracerebral hemorrhages. Long-standing hypertension with degenerative changes in the vessel walls and subsequent rupture is believed to be the most common cause of a typical cerebellar hemorrhage.

Hemorrhage from tumors, blood dyscrasias, amyloid angiopathy, arteriovenous malformations, trauma, sympathomimetic abuse, and genetic disorders such as CADASIL are less common causes of CH.[1]

Cerebellar hemorrhages are occasionally reported in patients following supratentorial surgery, spinal surgery, and in patients with spontaneous intracranial hypotension.[2, 3] The mechanism is thought to be removal of large amounts of cerebrospinal fluid (CSF) or continuing CSF leak from dural breach. The hemorrhage is remote from the surgical site or anatomic defect and may result from transient occlusion or rupture of superior cerebellar bridging veins.

Location of the hemorrhage (midline vs hemispheric) is important in determining symptoms and clinical course. It may be more important than absolute hematoma size for prognosis. Generally speaking, the more lateral the hemorrhage and the smaller the hematoma, the more likely the brainstem structures are spared and the better the prognosis.

Development of obstructive hydrocephalus from ventricular compression may lead to increased intracranial pressure and decreased cerebral perfusion pressure.

Brainstem damage by compression from an expanding mass in the posterior fossa is a common and feared complication.

Epidemiology

Frequency

United States

An estimated 10% of intracerebral hemorrhages are believed to be cerebellar in location. An estimated 1-2% of strokes are CHs.

International

Up to 30-45% of strokes are intracerebral hemorrhages in some Chinese and Japanese series. Approximately 10% of these may be cerebellar in origin.

Mortality/Morbidity

Mortality rates are unknown but are related to the size of the hematoma, location, and compression of adjacent brainstem structures. In one study, researchers found mortality was closely linked to the level of consciousness. Only 1 out of 8 non-comatose patients died, whereas 10 out of 18 comatose patients died.[4]

Race

In US population studies, CH is more common in blacks than in other races.

Sex

No gender predilection exists for CH.

Age

CH may occur at any age, depending on the etiology. Generally, incidence increases with age; most hypertensive hemorrhages occur in patients older than 50 years. Rupture of a vascular malformation may be the most common cause in children.

 

Presentation

History

Onset of 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 also 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.[5]

Causes

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

  • Hypertension - Suspected rupture of small penetrating vessels

  • Amyloid angiopathy

  • 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.

  • CADASIL[1]

 

DDx

 

Workup

Laboratory Studies

Obtain coagulation studies and a platelet count in all patients, particularly those taking anticoagulant medication.

Obtain other admission laboratory work (including a specimen for blood type and crossmatch) if surgery is a possibility.

Imaging Studies

Computed tomography

Acute CH should be visible as a hyperdensity in the posterior fossa.

Large hemorrhage of cerebellar vermis. Large hemorrhage of cerebellar vermis.

Note the location of the hematoma (central versus lobar) and any sign of brainstem compression.

Note the absolute size of the clot in maximum diameter, and the volume of the hematoma.

Other signs of a posterior fossa mass include ablation of the fourth ventricle and/or compression of the ambient and quadrigeminal cisterns.

Note any obstructive hydrocephalus.

Vascular imaging such as CT angiography, MR angiography, or catheter angiography of the intracranial vessels should be obtained to rule out the presence of an arteriovenous malformation, fistula, or aneurysm

MRI may be important later in the clinical course to define vascular anatomy, extent of damage, and other pertinent intracranial abnormalities (eg, tumor, arteriovenous malformation).

 

Treatment

Medical Care

Surgical care has been the mainstay of therapy for CH, although some patients with small hematomas may be treated successfully without surgery. There has been a call for large prospective randomized controlled trials to determine best treatment.[6]

Recent efforts have focused on improving patient selection for surgery, both in identifying patients who are candidates for nonsurgical management and identifying those in whom intensive therapy is likely to be futile.

Variation in patient selection for surgery is common, and only general guidelines are outlined here. Consultation with a neurosurgeon is indicated for all patients.

Most investigators agree that a patient who is awake and has a Glasgow coma scale score of 14 or greater (some investigators say 9 or greater) with a small hemorrhage (some investigators say < 30 mm diameter, others < 40 mm diameter) without hydrocephalus may be a candidate for conservative supportive care with close monitoring. (See the Glasgow Coma Scale calculator.)

If the patient's condition deteriorates, re-evaluate and reconsider surgery. In addition to neurologic deterioration, development of brainstem compression or hydrocephalus are indications for surgical treatment.[7]

Clot location (medial or lateral) is also a factor in patient selection for surgery.

Almost all agree that a patient who is comatose, flaccid, and without brainstem reflexes with a large midline hemorrhage has a poor prognosis. For such patients, supportive care without surgery may be the only indicated therapy. For infratentorial hemorrhages, the GCS has been shown to be a predictor of outcome.[8]

However, clear consensus does not exist regarding many patients who fall between these extremes. Variation in surgical treatment exists even within a geographic region.

Immediate management consists of stabilization and resuscitation.

Oxygen supplementation may be indicated.

Perform endotracheal intubation if required for airway management in patients with a decreased level of consciousness.

Use rapid sequence technique with precautions for increased intracranial pressure (ICP).

Correct fluid deficit with isotonic saline.

Hyperosmolar therapy with mannitol or hypertonic saline may be considered preoperatively in patients with a tight posterior fossa, although not much data exist to support these agents.

Persistent hypertension (mean arterial pressure >130 mm Hg) may indicate judicious use of labetalol or another titratable antihypertensive agent, such as nicardipine.

In symptomatic bradycardia reflecting Cushing response, atropine (0.5-1 mg) may be beneficial if hypotension is present.

Surgical Care

Indications for surgery remain controversial.[9]

Ventriculostomy may be indicated in patients with hemorrhage and hydrocephalus but is controversial as well, and is not recommended as an alternative to surgical evacuation as it may in turn be harmful.[9, 7]

Suboccipital craniotomy with clot evacuation is indicated in patients with altered level of consciousness and a large clot (see discussion in Medical Care; clot size >30-40 mm in greatest diameter).

American Heart Association/American Stroke Association guidelines previously gave a high-level recommendation for surgical removal of hematoma smaller than 30 mm in patients who are deteriorating neurologically or have brain stem compression and/or hydrocephalus from ventricular obstruction,[10, 11] but a specific size recommendation is lacking in more recent recommendations.[9, 11]

Patients with a large central clot and absent brainstem reflexes have a poor prognosis. In these cases, some advocate supportive therapy only.

Patients may appear to be in stable condition but can worsen suddenly. St Louis et al list clinical and CT findings that may identify patients who are at risk for deterioration.[12]

  • Admission systolic blood pressure greater than 200 mm Hg

  • Pinpoint pupils and abnormal corneal and oculocephalic reflexes

  • Hemorrhage extending into the cerebellar vermis

  • Hematoma diameter greater than 30 mm

  • Brainstem distortion

  • Intraventricular hemorrhage

  • Upward herniation

  • Acute hydrocephalus

  • Clot evacuation and direct fibrinolysis of the hematoma has been reported in small numbers of carefully selected patients.[13, 14, 15, 16]

  • Endoscopic hematoma evacuation has also been reported to have been effective in a small number of patients.

Consultations

It is reasonable to consult neurosurgery for all patients, even those who are candidates for conservative management. Sudden deterioration may require neurosurgical intervention.

After the clinical condition stabilizes, physical therapy, speech therapy, and occupational therapy are strongly recommended.

 

Medication

Medication Summary

No specific drug therapy exists for CH. Medications useful in treating hypertension (eg, labetalol, nicardipine) and increased ICP (eg, mannitol) may have a limited role in the acute phase. See the article Intracranial Hemorrhage for details.

Patients with an identified coagulopathy may require fresh frozen plasma or other products such as prothrombin complex concentrate that are specific for the coagulopathy. There is great heterogeneity in clinical practice for treatment of patients with intracerebral hemorrhage regarding blood pressure management, treatment of coagulopathy, and treatment of patients on antiplatelet therapy. Though no specific information addresses consideration of patients with cerebellar hemorrhage, it seems reasonable to extrapolate some concepts. For patients on antiplatelet therapy, transfusion of platelets or treatment with desomopressin (DDVAP) may be considered but are not routinely recommended.[17] Further study is needed.

 

Follow-up

Further Outpatient Care

Physical and occupational therapy may be useful in many patients.

Further Inpatient Care

Ideally, admit patients to the care of critical care physicians with expertise in managing intracranial hemorrhages.

Careful monitoring for level of consciousness, vital signs, and ICP is needed for some patients.

The risk of sudden deterioration is high and mandates the attention that is available in an intensive care unit.

If immediate surgical intervention is deferred, a deteriorating clinical course may necessitate surgery at a later time.

  • Posterior fossa craniotomy and evacuation of the hemorrhage may be necessary for patients with worsening clinical condition.

  • If surgical therapy is prompt, some comatose patients still may have a good clinical outcome.

Physical and occupational therapy may be useful in patients who are in stable condition.

Transfer

For facilities without neurosurgical care for hemorrhage management, transfer to a specialized center should occur after stabilization.

  • Transfer should occur only after discussion with an accepting physician.

  • Transfer personnel should be skilled in critical care management.

Complications

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

Prognosis

Prognosis is largely related to the size and location of the hemorrhage and the patient's clinical condition at the time of clinical presentation.

Patient Education

For patient education resources, see the Stroke Center, as well as Stroke.