Presentation
Severe headache, ataxia, and confusion, with a background of hypertension and diabetes mellitus.
Patient Data
Hypodensity in some parts of the cerebellar hemisphere with indistinct grey-white matter differentiation mainly on the right side. Normal appearance of both cerebral hemispheres.
Normal lateral, third, and fourth ventricles.
Prominent hypodensity of both cerebellar hemispheres with near-symmetrical prominent swelling and hypodense areas involve both the superior and middle cerebellar hemispheres, with effacement of the cerebellar folia and loss of grey-white matter differentiation.
The outflow of the fourth ventricle is effaced with compression of the pons and the midbrain, along with the aqueduct of Sylvius, is causing hydrocephalus.
Ascending transtentorial herniation with superior displacement of the superior parts of the cerebellum through the tentorial notch, resulting in:
flattening of the quadrigeminal cistern
spinning top appearance of the midbrain
Case Discussion
This case illustrates the association between the clinical presentation, including rapid deterioration, and the CT findings, which show bilateral cerebellar infarctions in both superior cerebellar artery territories as well as ascending transtentorial herniation.
The cause of simultaneous bilateral cerebellar infarction is probably related to an anatomical variant of the superior cerebellar arteries and basilar artery (e.g. top of basilar thrombus, with large posterior communicating arteries protecting the posterior cerebral arteries). Further assessment with CTA or MRI and MRA would help confirm the cause.
Unfortunately, the patient fell into a coma and died on the same day as the second CT scan due to complications from compressive hydrocephalus and concomitant brainstem infarction rather than the cerebellar infarction itself.
Decompressive surgery can be performed, especially in cases of massive cerebellar infarction causing supratentorial hydrocephalus and brainstem compression to prevent progressive brainstem signs, impaired consciousness, or even death.
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