Bilateral Cerebellar Hemorrhage Research Articles

Atypical bilateral cerebellar hemorrhage due to recreational drug use

Atypical bilateral cerebellar hemorrhage due to recreational drug use

Remote cerebellar hemorrhage following repeated lumbar punctures

BackgroundRemote cerebellar hemorrhage (RCH) is a rare complication in neurosurgery. No case of RCH secondary to repeated lumbar punctures (LPs) has been previously reported.Case presentationA 49-year-old man presented with impaired consciousness following persistent fever. Cerebrospinal fluid examination showed high opening pressure, elevated white blood cells, increased protein level, and decreased glucose level, resulting in a diagnosis of bacterial meningoencephalitis. Treatment with repeated LPs and intrathecal injection of ceftriaxone resulted in an improvement in neurological symptoms. However, on day 31 of treatment, brain magnetic resonance image (MRI) showed streaky bleeding in bilateral cerebellum (zebra sign), leading to a diagnosis of RCH. Close observation and repeated brain MRI imaging without specific treatments led to the absorption of bilateral cerebellar hemorrhage, and the patient was discharged with improved neurological symptoms. Repeated brain MRI scans one month after discharge showed that bilateral cerebellar hemorrhage had improved, and had disappeared one year after discharge.ConclusionWe reported a rare occurrence of LPs-induced RCH presenting as isolated bilateral inferior cerebellar hemorrhage. Clinicians should be vigilant of the risk factors for RCH, closely monitoring patients' clinical symptoms and neuroimaging findings to determine the need for specialized treatment. Furthermore, this case highlights the importance of ensuring the safety of LPs and managing any potential complications appropriately.

Intracranial Hemorrhage Caused by Acute-Onset Severe Hypernatremia.

A 52-year-old unemployed Japanese woman with depression was brought to our emergency department (ED) after an attempted suicide. She had reportedly ingested 1500 mL of soy sauce (corresponding to 277.5 g sodium chloride) 60 min before presentation. She was taking prescribed mirtazapine, 15 mg daily. In the ED, she was agitated, and a physical examination revealed a Glasgow Coma Scale (GCS) score of 14 (E4V4M6), a respiratory rate of 20 breaths/min, an oxygen saturation of 100% on room air, a blood pressure of 115/94 mmHg, a pulse rate of 110/min, and a temperature of 35.6℃. As her initial blood [Na] was 171 mEq/L (serum [Na] was 173mEq/L), 5% dextrose solution (D5W) was intravenously administered. At 30 min post-arrival, a second blood analysis revealed an increase in her blood [Na] to 179 mEq/L and her consciousness level dropped to a GCS score of 7 (E1V2M4) with a convulsive seizure. A plain computed tomography (CT) of the head revealed bilateral cerebellar hemorrhage. An intravenous bolus administration of D5W lowered her blood [Na] from 179 to 162 mEq/L over a period of 40 min, which improved her consciousness. After this rapid correction, her blood [Na] was lowered at a rate of 0.55 mEq/L per hour. Although magnetic resonance imaging (MRI) of the head, performed on day 7, revealed hydrocephalus and cerebellar edema, she was asymptomatic. She was discharged on day 57 without neurological sequelae.

Abstract 1122‐000171: Unusual Multicompartmental Intracranial Hemorrhage After Tenecteplase Administration

Introduction : The 2019 AHA/ASA updated Guidelines for the Early Management of Patients with Acute Ischemic Stroke mention tenecteplase (TNK) as a reasonable therapy in patients without contraindications for IV fibrinolysis who are also eligible to undergo mechanical thrombectomy. We describe a case of acute left MCA ischemic stroke treated with IV TNK (IV bolus of 0.25 mg/kg) followed by mechanical thrombectomy with subsequent multicompartmental intracranial hemorrhages unrelated to area of infraction. Methods : A retrospective review at a single center university hospital was performed for all intravenous TNK administrations outside of a clinical trial setting from October 2020 to July 2021. Results : A 61‐year‐old male with history of HTN and cardiomyopathy (EF<20%). Presented with sudden onset right sided weakness, aphasia and left gaze. Presenting NIHSS was 28. CT head with hyperdense left MCA sign and ASPECTS score of 10. CTA confirmed proximal left MCA M1 segment occlusion. IV TNK was given within 01:23 hours of symptoms onset. Subsequently, patient underwent emergent mechanical thrombectomy for disabling large vessel occlusion stroke. Spontaneous near complete recanalization of left MCA occlusion was noted on initial angiography run with small non flow limiting distal thrombi visualized in the distal MCA territories. Immediate post procedure CT head was negative for any intracranial hemorrhage. Patient’s exam was noted to improve to NIHSS of 2. Approximately 6 hours after the TNK administration, patient became acutely unresponsive with NIHSS of 26. With Glasgow Coma Scale 7 patient required emergent intubation. CT head revealed bilateral cerebellar intraparenchymal hemorrhages, extensive subarachnoid hemorrhage in basal cisterns and within the sulci in bilateral frontotemporal regions, as well as subdural hemorrhages along the falx and tentorial dural folds. Hypertonic saline was administered followed by emergent extraventricular drain placement. Tranexamic acid 1000 mg was given as emergent reversal, fibrinogen level was 155 mg/dL. Despite aggressive medical management and over following 24 hours, exam worsened with loss of pupillary reflexes. Patient was terminally extubated 2 days after initial presentation in accordance with his advance directives. Conclusions : Tenecteplase was a reasonable choice in this case given LVO and disabling stroke. The patient’s neurological exam improved significantly after TNK with evidence of spontaneous recanalization. However, patient’s multicompartmental intracranial hemorrhages unrelated to area of infraction were unusual in the absence of any vascular lesions to predispose hemorrhage based on CT and conventional angiography. Further observational studies are warranted to evaluate similar complications of Tenecteplase administration and their occurrence rates.

An Unusual Cause of Concordance in the Setting of Left Bundle Branch Block

A 73-year-old female with a past medical history of atrial fibrillation, mechanical mitral valve replacement on warfarin, hypertension and hypothyroidism presented to the emergency department with a fall. She fell and hit her head upon standing up from a seated position. She reported a constant posteriorly located headache along with episodes of nausea and vomiting. She denied chest pain, shortness of breath, syncope and fever. The initial examination showed blood pressure of 107/64mmHg, respiratory rate of 13/Min, pulse of 76/Min, oxygen saturation of 96% and Glascow Coma Scale (GCS) of 13, verbal response 4, motor response 6 and eye response 3. Pupils were round and reactive to light. No focal weakness or sensory loss were noted. The patient’s mental status and GCS progressively worsened for which she eventually was intubated. The patient had a mild leukocytosis of 14.11×109 (4.0-10.0). Her sodium, calcium, magnesium, phosphorus and potassium were normal. International Normalized Ratio (INR) was 2.9. The troponin upon presentation was 0.69ng/ml and trended down throughout the hospitalization. Her EKG showed normal sinus rhythm with a left bundle branch block with ST segment elevation in leads V3 - V5 and concordant ST elevation >1mm in V5. Sgarbossa criteria for acute myocardial infarction in the presence of LBBB was 5 points. Computed tomography (CT) scan of the head without contrast showed large bilateral cerebellar hemorrhages with mild inferior herniation of the cerebellar tonsils. Echocardiogram showed ejection fraction of 55-60% with no wall motion abnormalities. Immediate supportive treatment, including fluids and reversal of anticoagulation with prothrombin complex concentrate and vitamin K were administered. The patient underwent a successful suboccipital decompressive craniotomy.

Rare Case of Bilateral Cerebellar Hemorrhage in a Male Boxer.

The sport of boxing carries with it the risk of brain injury with acute and chronic neurological injuries such has contusion, concussion and intracranial bleeding has been reported. The force sustained from a boxing blow can be as powerful as being hit with a 6-kg wooden mallet striking at 20 mph. Bilateral cerebellar hemorrhage secondary to trauma is a rare entity that has not been reported in the literature previously. One can only speculate as to how a boxer could potentially develop a cerebellar bleed. Regardless of whether a very powerful punch or the act of falling back and hitting the occipital region directly on the floor, it is very likely that a predisposing factor exist. We present you a rare case of a 26 year-old male boxer who was knocked out in a boxing match and was noted to have acute parenchymal and subarachnoid hemorrhage bilaterally in the cerebellar hemispheres. Our report highlights the need to consider cerebellar bleed in boxers who present after ataxia after boxing/knocked out.

Paroxysmal Sympathetic Hyperactivity with Dystonia Following Non-traumatic Bilateral Thalamic and Cerebellar Hemorrhage

Paroxysmal Sympathetic Hyperactivity with Dystonia Following Non-traumatic Bilateral Thalamic and Cerebellar Hemorrhage

Paroxysmal sympathetic hyperactivity with dystonia following bilateral thalamic and cerebellar hemorrhage: a case report (P6.330)

Paroxysmal sympathetic hyperactivity with dystonia following bilateral thalamic and cerebellar hemorrhage: a case report (P6.330)

Bilateral remote cerebellar hemorrhage following surgical clipping a ruptured supratentorial aneurysm

Remote cerebellar hemorrhage (RCH) is a rare and severe complication after supratentorial surgery, with various risk factors and mechanisms remaining uncertain. Herein, we report a 64-year-old female patient suffered bilateral RCH following surgical clipping a ruptured aneurysm of internal carotid artery bifurcation. RCH is considered as venous in origin, and is likely the result of intra-operative or post-operative loss of CSF. Thus, appropriate control and close monitor the intra-operative and post-operative loss of CSF is of great importance for preventing the occurrence of RCH.

Intracerebral hemorrhage after intravenous thrombolysis in patients with cerebral microbleeds and cardiac myxoma.

Background and purpose: Cardiac myxoma is a rare etiology of stroke. Both cerebral microbleeds and cardiac myxoma may increase the risk of intracerebral hemorrhage after intravenous (IV) thrombolysis. However, data are still limited. We report a case of multiple cerebral microbleeds treated with IV thrombolysis with later findings of cardiac myxoma.Summary of case: A 58-year-old-man presented with right-sided hemiplegia and global aphasia. The presumptive diagnosis of acute left middle cerebral artery (MCA) infarction was made. Previous magnetic resonance imaging showed multiple cerebral microbleeds. The patient received IV thrombolysis. Bilateral cerebellar hemorrhage occurred after thrombolysis, and a median suboccipital craniectomy and hematoma removal was performed. Transthoracic echocardiogram found a left atrial myxoma. The tumor was then surgically removed. Six months later, neurological deficit improved.Conclusion: Cerebral microbleeds may be associated with atrial myxoma. IV thrombolysis could benefit acute ischemic stroke patients with both baseline cerebral microbleeds and atrial myxoma.

Bilateral cerebellar hemorrhage in vermian vein thrombosis

A 67-year-old previously healthy man presented with sudden onset of headache, vomiting, and instability of stance and gait. Neurologic examination demonstrated bilateral dysmetria of the limbs, ataxia, and scanning speech. Neuroimaging showed bilateral cerebellar hemorrhage and altered signal of the superior vermian vein suggestive for thrombosis (figures 1 and 2). Workup for hematologic, coagulation, and immunologic disorders was negative. Acknowledgment : The authors thank Dr. Francesca Lupidi (Neurological Clinic, University Hospital of Ancona, Italy) and Dr. Natalie Herber (Department of Neuroradiology, University Hospital of Ancona, Italy) for editing assistance.

Teaching Neuro Images : Remote cerebellar hemorrhage following resection of a supratentorial tumor

A 23-year-old man was admitted with blurred vision and headache. Ten years ago he was diagnosed with a left temporal pleomorphic xanthoastrocytoma; his last resection was 6 years ago. Current CT and MRI showed left temporal encephalomalacia; MRI also revealed incidental bilateral remote cerebellar hemorrhages (RCH) (figure). Called “remote” due to their distance from the surgical site, RCH are rare complications of supratentorial and spinal operations.1 Depending on extent, RCH may be symptomatic and diagnosed acutely on CT, or incidentally discovered as …

Recurrent, sequential, bilateral deep cerebellar hemorrhages: a case report

IntroductionHypertensive intra-cerebral hemorrhage is usually a one-time event and recurrences are rare. Most recurrences develop as part of long-term failure of blood pressure control. The site of the re-bleed is usually limited to the basal ganglia and thalami.Case presentationWe report the case of a 59-year-old hypertensive Caucasian woman who developed two sequential, right- and then left-sided, deep cerebellar hemorrhages. The second hemorrhage followed the first one by 57 days, at a time when her blood pressure was optimally controlled. In spite of these critical sites and short duration between the two bleeds, the patient achieved a relatively good functional recovery. Her brain magnetic resonance angiogram was unremarkable.ConclusionThe development of recurrent hypertensive hemorrhage is rare and usually occurs within two years of the first bleed. To the best of our knowledge, this is the first reported case of bilateral, sequential, right- and then left-sided deep cerebellar hemorrhages. These hemorrhages were separated by eight weeks and the patient had a relatively good functional recovery. We believe that hypertension was the etiology behind these hemorrhages.

Stroke in Patients with Dengue

Central nervous system infections are one of the common causes of stroke in developing countries. Stroke after dengue is uncommon. A total of 1148 dengue cases were seen in a tertiary referral hospital during the epidemic from September to November 2008. We present 3 patients who had stroke caused by dengue. The first patient was a 45-year-old woman with dengue hemorrhagic fever who developed sudden right arm and leg weakness. Magnetic resonance imaging (MRI) revealed multiple hemorrhagic foci in the left parietal and temporal lobes. The second patient was a 35-year-old man who developed fever that was followed by altered sensorium and quadriparesis. MRI showed bilateral cerebellar hemorrhages with edema, obstructive hydrocephalus, and multiple watershed infarcts. The third patient was a 70-year-old woman who presented with giddiness for 2 days followed by sudden weakness of the left side of the body. She developed fever after admission. MRI showed infarct in the right parietal lobe. All the patients had low platelet count and one patient died. Dengue might be an important cause of stroke in epidemic regions when patients present with fever, focal neurologic deficits, and encephalopathy.

Cerebellar Cleft: Confirmation of the Neuroimaging Pattern

We recently described the neuroimaging and clinical findings in 6 children with cerebellar clefts and proposed that they result from disruptive changes following prenatal cerebellar hemorrhage. We now report an additional series of 9 patients analyzing the clinical and neuroimaging findings. The clefts were located in the left cerebellar hemisphere in 5 cases, in the right in 3, and bilaterally in one child who had bilateral cerebellar hemorrhages as a preterm infant at 30 weeks gestation. In one patient born at 24 weeks of gestation a unilateral cerebellar hemorrhage has been found at the age of 4 months. Other findings included disordered alignment of the folia and fissures, an irregular gray/white matter junction, and abnormal arborization of the white matter in all cases. Supratentorial abnormalities were found in 4 cases. All but 2 patients were born at term. We confirm the distinct neuroimaging pattern of cerebellar clefts. Considering the documented fetal cerebellar hemorrhage in our first series, we postulate that cerebellar clefts usually represent residual disruptive changes after a prenatal cerebellar hemorrhage. Exceptionally, as now documented in 2 patients, cerebellar clefts can be found after neonatal cerebellar hemorrhages in preterm infants. The short-term outcome in these children was variable.

Neonatal Cranial Ultrasound Lesions and Developmental Delays at 2 Years of Age Among Extremely Low Gestational Age Children

Studies of the relationship between ultrasound images from preterm newborns and developmental delay most often are based on small samples defined by birth weight and exclude infants not testable with standardized assessments. We evaluated associations between ultrasound-defined lesions of the brain and developmental delays at 24 months' corrected age in 1017 children born before the 28th postmenstrual week. Brain ultrasound scans were read for concordance on 4 lesions: intraventricular hemorrhage, moderate/severe ventriculomegaly, white matter echodense/hyperechoic lesions, and white matter echodense/hypoechoic lesions and 2 diagnoses-periventricular leukomalacia and periventricular hemorrhagic infarction. Certified examiners, who were not aware of the infants' ultrasound findings, administered the Bayley Scales of Infant Development-Second Edition. Children with an impairment (eg., blindness) that precluded testing with the Bayley Scales and those for whom >2 test items were omitted were classified using the Vineland Adaptive Behavior Scales Motor Skills Domain instead of the Psychomotor Development Index and the Adaptive Behavior Composite instead of the Mental Development Index. Fully 26% of all of the children had delayed mental development (ie, Mental Development Index < 70), and 31% had delayed psychomotor development (ie, Psychomotor Development Index < 70). Ultrasound abnormalities were more strongly associated with low Psychomotor Development Index than with low Mental Development Index. Children without cranial ultrasound abnormality had the lowest probability (23% and 26%) of delayed mental or psychomotor development. Moderate/severe ventriculomegaly was associated with a more than fourfold increase in the risk of psychomotor delay and an almost threefold increase in the risk of mental delay. Echolucency was the next best predictor of delayed mental and psychomotor development. The probability of low scores varied with the number of zones involved and with the location of echolucency. At particularly high risk were infants with bilateral cerebellar hemorrhage, co-occurring ventriculomegaly and echolucency bilateral echolucency, or echolucency located posteriorly. Focal white matter damage, as characterized by echolucent/hypoechoic lesion, and diffuse damage, as suggested by late ventriculomegaly, are associated with delayed mental and psychomotor development.

Successful endovascular treatment of a deep cerebral arteriovenous fistula with unusual venous drainage

Background Cerebral arteriovenous fistula (AVF) is a rare disease. We present one adult with a deep cerebral AVF presented with cerebellar hemorrhage. Case description A 35-year-old man suddenly experienced headache, vomiting, dysarthria and ataxia of gait. Computed tomography (CT) demonstrates bilateral cerebellar hemorrhage. Angiography revealed a cerebral AVF fed by the bilateral medial posterior choroidal arteries and drained into the supratentorial deep venous system with flow into the infratentorial venous system. The draining veins included three varices, one of which, in the cerebellar vermis, was thought to be the source of bleeding. The patient was treated with transarterial embolization using n-butyl-cyanoacrylate (NBCA) and detachable platinum coils. Although coil migration during endovascular treatment occurred, complete closure of the fistula without morbidity and mortality was obtained. Conclusion Direct intracranial arteriovenous fistula with supra and infra tentorial venous drainage is rare; it can present with intracranial hemorrhage and can be treated by endovascular therapy.

Impaired trophic interactions between the cerebellum and the cerebrum among preterm infants.

Advanced neuroimaging techniques have brought increasing recognition of cerebellar injury among premature infants. The developmental relationship between early brain injury and effects on the cerebrum and cerebellum remains unclear. To examine whether cerebral parenchymal brain lesions among preterm infants are associated with subsequent decreases in cerebellar volume and, conversely, whether primary cerebellar injury is associated with decreased cerebral brain volumes, with advanced, 3-dimensional, volumetric MRI at term gestational age equivalent. Total cerebellar volumes and cerebellar gray and myelinated white matter volumes were determined through manual outlining for 74 preterm infants with unilateral periventricular hemorrhagic infarction (14 infants), bilateral diffuse periventricular leukomalacia (20 infants), cerebellar hemorrhage (10 infants), or normal term gestational age equivalent MRI findings (30 infants). Total brain and right/left cerebral and cerebellar hemispheric volumes were calculated. Unilateral cerebral brain injury was associated with significantly decreased volume of the contralateral cerebellar hemisphere. Conversely, unilateral primary cerebellar injury was associated with a contralateral decrease in supratentorial brain volume. Cerebellar gray matter and myelinated white matter volumes were reduced significantly not only among preterm infants with primary cerebellar hemorrhage but also among infants with cerebral parenchymal brain injury. These data suggest strongly that both reduction in contralateral cerebellar volume with unilateral cerebral parenchymal injury and reduction in total cerebellar volume with bilateral cerebral lesions are related to trophic transsynaptic effects. Early-life cerebellar injury may contribute importantly to the high rates of cognitive, behavioral, and motor deficits reported for premature infants.

Cerebellar venous infarction

A diabetic man developed a severe hyperosmolar state resulting in coma. CT of the head showed bilateral cerebellar hemorrhages. Despite medical treatment, he deteriorated and died. At autopsy, the straight sinus was thrombosed. There were bilateral, hemorrhagic, cerebellar venous infarctions. This condition is rare because of abundant collateral venous drainage.