Cerebellar haemorrhages are a common form of intracerebral haemorrhage (ICH) and usually occur due to poorly controlled long-standing hypertension, although other causes also exist. When due to chronic hypertension, the stigmata of chronic hypertensive encephalopathy are often present (see: cerebral microhaemorrhage).
There are many causes of cerebellar haemorrhage, this article is focused on primary cerebellar haemorrhages.
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Epidemiology
The demographics of affected patients usually reflect those of patients with long-term poorly controlled hypertension, and as such patients are usually middle-aged to elderly (>5th decade) 6. Cerebellar haemorrhages account for ~10% of all intracerebral haemorrhages and ~15% of cerebellar strokes 3,9.
Clinical presentation
Clinical presentation depends on the size of the haemorrhage. Small cerebellar haemorrhages can present with typical "posterior circulation symptoms" of vertigo, ataxia, nausea, vomiting and headache. These can be sudden onset and occur during exercise or stress situations 6. Larger haemorrhages can present with reduced consciousness 6.
Pathology
Cerebellar haemorrhage can be due to 6:
hypertension (most common): most commonly located deep/centrally at the dentate nuclei
underlying lesion, e.g. tumour, arteriovenous malformation, intracranial aneurysm, dural arteriovenous fistula
cerebral amyloid angiopathy: can be suggested when the haemorrhage is solely located superficially/peripherally at the cerebellar cortex and/or vermis 7
supratentorial surgery (see: remote cerebellar haemorrhage)
Radiographic features
CT is usually the first, and often the only, imaging investigation obtained. Serial imaging may be required to evaluate for haematoma expansion, posterior cranial fossa mass effect and/or the development of hydrocephalus 10.
CT
As with other acute intracranial haemorrhages, cerebellar haemorrhages appear as regions of hyperdensity within the cerebellar hemispheres. Extension into the fourth ventricle or subarachnoid space is relatively common 9.
If there is no extension into the ventricular system, the volume of the haemorrhage can be estimated using ABC/2 8, which may have treatment implications.
There are many predictors of haematoma expansion potentially evident on CT, which are discussed in depth in the main intracerebral haemorrhage article.
MRI
The appearance of haemorrhage on MRI varies with time and to some degree the size of the haematoma (see ageing blood on MRI).
Treatment and prognosis
Overall, medical management does not differ for other causes of intracerebral haemorrhage - please see the article on intracerebral haemorrhage for further discussion 11.
In contrast to management of intracerebral haemorrhages in other locations, neurosurgical intervention is more common in cerebellar haemorrhages. Cerebellar haemorrhages are often complicated by hydrocephalus, brainstem compression, and/or cerebellar herniation, and thus surgical haematoma evacuation via craniotomy +/- extraventricular drain (if needed for hydrocephalus) is often recommended despite the absence of high-level evidence 11. These interventions are thought to reduce mortality compared to non-surgical treatment although may not improve functional outcomes 8,11. Indications for evacuation include 8,11:
neurological deterioration
brainstem compression
obstructive hydrocephalus
cerebellar haemorrhage volume ≥15 mL
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