Makindo Medical Notes

Related Subjects: |Subarachnoid Haemorrhage |Perimesencephalic Subarachnoid haemorrhage |Haemorrhagic stroke |Cerebellar Haemorrhage |Putaminal Haemorrhage |Thalamic Haemorrhage |ICH Classification and Severity Scores |Brain Herniation syndromes |Epidural Haematoma

⏱️ Timely recognition and neurosurgical evacuation can be lifesaving in cerebellar haemorrhage, offering patients the potential for excellent recovery.

📖 About

• Cerebellar haemorrhage accounts for ~10% of all intracerebral haemorrhages.
• Causes acute, often persistent vertigo, nausea, vomiting, and imbalance, sometimes mimicking labyrinthitis or intoxication.
• Deterioration can be rapid due to brainstem compression or acute hydrocephalus.

📍 Location & Prognosis

• Midline (vermis) lesions: Higher risk — deep cerebellar nuclei and 4th ventricle involvement, often severe.
• Hemispheric lesions: Lateral bleeds usually have a better prognosis if detected early.

⚡ Causes

• Hypertensive rupture of penetrating arteries (most common).
• Cerebral amyloid angiopathy (elderly).
• Substance misuse (cocaine, amphetamines).
• Arteriovenous malformations, cavernomas.
• Haemorrhagic tumours or metastases.
• Anticoagulant use, thrombocytopenia, or clotting disorders.
• Post-spinal/neurosurgical complications, spontaneous intracranial hypotension.

🧑‍⚕️ Clinical Presentation

• Sudden severe headache, nausea, vertigo, vomiting.
• Ipsilateral cerebellar signs: limb ataxia, intention tremor, nystagmus.
• Cranial nerve VI & VII involvement possible → diplopia, facial weakness.
• Truncal ataxia: inability to walk unaided, frequent falls.
• Severe cases: brainstem compression → coma, pinpoint pupils, abnormal breathing (Cheyne–Stokes).

🚩 Poor Prognostic Indicators

• Haematoma diameter >3 cm 📏
• Acute hydrocephalus (4th ventricle obstruction)
• Brainstem compression, herniation
• Midline location or intraventricular extension
• Low GCS at presentation

🔍 Differential Diagnosis

• Brainstem infarction (posterior circulation stroke)
• Peripheral vestibular disorders (labyrinthitis, vestibular neuritis)
• Alcohol intoxication or drug toxicity (esp. anticonvulsants)
• Multiple sclerosis relapse (rare mimic)

🧪 Investigations

• Bloods: FBC, coagulation screen (INR if warfarin), U&E, LFTs, glucose.
• ECG, chest X-ray (perioperative/medical optimisation).
• Urgent non-contrast CT: gold standard for diagnosis; defines bleed size, location, hydrocephalus, mass effect.
• MRI: in stable patients, helps detect underlying lesions (AVM, tumour, cavernoma).

🛠️ Management

• Stabilisation (ABC): Airway protection, oxygenation, BP control, and ICU/ITU consideration.
• Surgical evacuation:
  • Indicated if clot >3 cm, GCS <14, or acute hydrocephalus.
  • Suboccipital craniectomy + clot evacuation can be lifesaving.
  • External ventricular drain (EVD) may relieve hydrocephalus, often alongside clot evacuation.
• Medical therapy:
  • Osmotic therapy (Mannitol 1 g/kg) as a bridge in raised ICP.
  • Reversal of anticoagulation (e.g., Vitamin K + PCC for warfarin).
  • Cautious BP lowering to reduce rebleed risk.
• Conservative management: Consider if clot <3 cm, GCS preserved, and no hydrocephalus, but under close neurosurgical observation.
• Rehabilitation: Multidisciplinary input (physio, OT, speech therapy). Recovery can be remarkable compared to supratentorial bleeds.
• Palliative care: In cases with profound brainstem involvement and coma, discussions around ceiling of care may be necessary.