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cerebellar hemorrhage

Etiology: 1) hypertension (most common) 2) amyloid angiopathy (common in elderly) - suspect in patient with hemorrhage outside distribution common for hypertensive hemorrhage 3) arteriovenous malformations (AVM) 4) bleeding diatheses 5) pharmacologic anticoagulation 6) cocaine may be precipitating factor Pathology: - most commonly small penetrating vessels bleeding into the cerebellar parenchyma Clinical manifestations: 1) vertigo, headache, neck stiffness 1st symptoms [3] 2) imbalance 3) diplopia 4) lethargy 5) flaccid quadraplegia, decrebrate posture & coma if hemorrhage involves pons [3] 6) 1/3 of non-comatose patients deteriorate rapidly - 50% mortality 7) hematomas > 50 mL are most likely to cause deterioration 8) patients with amyloid-related hemorrhages a) frequently normotensive b) generally have prior cognitive deficits Laboratory: urine toxicology for cocaine Special laboratory: - cerebral angiography a) patients < 45 years of age b) intraparenchymal hemorrhage related to cocaine (high incidence of vascular anomalies) Radiology: - non-contrast computed tomography (CT) of the brain Management: 1) see general measures under stroke (CVA) 2) neurosurgery a) posterior fossa decompression - evacuation of hematoma > 3 cm, especially if neurologic deterioration or evidence of brainstem compression [2] b) craniotomy for arteriovenous malformation (AVM) 3) mannitol, barbiturate coma, hyperventilation to reduce intracranial pressure 4) IV nitroprusside, nicardipine or labetolol to maintain systolic blood pressure between 140-160 mm Hg [2] - assumption is that excessively high systolic blood pressure will increase hematoma size 5) avoid statins [3] 6) neurorehabilitation

Related

subarachnoid hemorrhage (SAH)

General

hemorrhagic stroke

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1019-20
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018
  3. Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016