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Remote Cerebellar Haemorrhage

Summary

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  • Rare complication following supratentorial or spinal surgery
  • Characterised by unexpected cerebellar haemorrhage distant from the operative site
  • Typically presents with delayed neurological deterioration post-surgery

Pathophysiology

  • Exact mechanism remains unclear, but leading theories include:
    • Cerebrospinal fluid (CSF) overdrainage leading to downward cerebellar displacement and venous stretching
    • Transient increase in intracranial pressure causing venous hypertension
    • Intraoperative head positioning causing alterations in venous drainage

Demographics

  • Incidence: 0.08% to 0.6% of supratentorial craniotomies
  • More common in:
    • Middle-aged to elderly patients
    • Patients with pre-existing coagulopathies
    • Cases involving significant CSF drainage during surgery

Diagnosis

  • Clinical presentation:
    • Delayed onset of symptoms (usually 16-72 hours post-surgery)
    • Decreased level of consciousness
    • Cerebellar signs (ataxia, dysmetria)
    • Headache and nausea/vomiting
  • Laboratory findings:
    • Coagulation profile may reveal abnormalities
    • CSF analysis typically normal unless complicated by infection

Imaging

  • CT findings:
    • Hyperdense cerebellar haemorrhage, often bilateral and symmetrical
    • Classic 'zebra sign' or 'streaked bleeding' pattern along cerebellar folia
    • May be accompanied by subarachnoid haemorrhage or intraventricular extension
  • MRI findings:
    • T1: Hyperintense signal in subacute stage
    • T2: Mixed signal intensity
    • Gradient Echo/SWI: Hypointense blooming artefact confirming haemorrhage
    • DWI: May show restricted diffusion in acute stage

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  • A 70-year-old patient with ventriculomegaly and a clinical diagnosis of normal pressure hydrocephalus was admitted for the insertion of a ventriculoperitoneal shunt.
  • The patient developed cerebellar haemorrhage on the first post-operative day.

Treatment

  • Management approach depends on severity:
    • Conservative management for small haemorrhages:
      • Close neurological monitoring
      • Blood pressure control
      • Reversal of coagulopathy if present
    • Surgical intervention for large haemorrhages or significant mass effect:
      • Posterior fossa decompression
      • Haematoma evacuation
  • Preventive measures:
    • Gradual CSF drainage during surgery
    • Careful positioning of the head during and after surgery
    • Meticulous haemostasis and management of coagulation parameters

Differential diagnosis

Differential Diagnosis Differentiating Feature
Cerebellar infarction haemorrhagic transformation Typically follows vascular territory; may have associated brainstem infarcts
Cerebellar tumour Usually more focal; may have mass effect and surrounding oedema
Cerebellar abscess Ring-enhancing lesion with restricted central DWI; surrounding vasogenic oedema
Cerebellar metastases Multiple lesions; ring or nodular enhancement; surrounding vasogenic oedema
Cerebellar contusion Associated overlying scalp/skull injury on CT; localised haemorrhage without supratentorial craniotomy site
Cerebellar arteriovenous malformation Serpiginous vascular structures; flow voids on MRI
Cerebellar venous thrombosis Venous infarction; may see thrombosed veins on imaging