Cerebellar Hemorrhage

Intern 胡朝凱2002/12/09

Pathophysiology Long-standing hypertension ----most common

cause Tumor Trauma Anticoagulant use Blood dyscrasias Arteriovenous malformation rupture Amyloid angiopathy

Key point Location ( midline vs. hemisphere ) Brain stem compression Size

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

Physical examination Alert or unconscious Irregular respiration Impaired or absent pupillary responses Abnormal eye movement

Impaired oculo-cephalic responses ( Doll eye ) Decreased or absent corneal responses Facial weakness Nuchal rigidity Possible presence of extensor plantar responses

(unilateral or bilateral)

Neural examination (0) Ipsilateral half body No definite functional location

Neural examination (1) Nystagmus -- up and down Dysarthria -- irregular, explosive, slurring

of words

Neural examination (2) Ataxia ( past-pointing ; dysmetria ) finger to nose test heel-to-shin test

Intention tremor Adiadochokinesis

pronation and supination test finger to thumb test

Asynergy decomposition of movements

Neural examination (3) Hypotonia Vermis syndrome

paraxial musculature, truncal ataxia Gait

wide-based, irregular, staggering, like an intoxicated person

Romberg’s sign Tandem walking

Lab study Coagulation studies and a platelet count

Imaging studies CT scan -- acute CH should be visible as

increased density in the posterior fossa Location Brainstem compression Absolute size of the clot in maximum diameter Ablation of the fourth ventricle Obstructive hydrocephalus

MRI -- vascular anatomy, extent of damage, and other abnormalities (eg, tumor, AVM)

Risk for deterioration Admission systolic blood pressure ＞ 200 mmHg Pinpoint pupils and abnormal corneal and

oculocephalic reflexes Hemorrhage extending into the cerebellar vermis Hematoma ＞ 30 mm Brainstem distortion Intraventricular hemorrhage Acute hydrocephalus

Criteria for medical conservative treatment Best --

Glasgow coma scale score of 14 or greater Small hemorrhage ( < 30 mm ) Without hydrocephalus

Worst -- Comatose Flaccid Without brainstem reflexes Large midline hemorrhage

Medical treatment O2

Fluid -- isotonic saline. Mannitol (1 g/kg) -- preoperatively in patients

with tight posterior fossa. Antihypertensive agent -- persistent hypertension

( mean arterial pressure >130 mm hg ) Atropine (0.5-1 mg) -- cushing response,

symptomatic bradycardia

Surgical intervention Controversial. Ventriculostomy -- hemorrhage and

hydrocephalus. Suboccipital craniotomy with clot

evacuation -- altered level of consciousness and a large clot (30 ~ 40 mm).

Further patient care: Careful monitoring

Consciousness Vital signs ICP

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

Physical and Occupational therapy.

Medical/legal pitfalls: Failure to diagnose and delayed diagnosis

following clinical deterioration. Small, lateral hemorrhage. Patients with diminished level of consciousness

or intractable vomiting unable to cooperate with examination.

Testing the gait complaint of dizziness accompanied by headache, nausea, vomiting, or obtundation.

Take-Home Message Headache

Worst First Days or weeks Fever Vomiting precedes

headache Disturbs sleep Abrupt Onset after age of 55

Neural examination Pupil Ocular movement Optic fundi Facial movement Muscle power DTR Pain and vibration

sense in hands and feet Gait

Thank You For Your Attention !! May God Bless Our Friends !!