Cerebellar haemorrhage

Case contributed by RMH Neuropathology

Presentation

10 days of headache and diplopia and left cerebellar signs.

Patient Data

Age: 51
Gender: Male

MRI Brain

Modality: MRI

MRI brain shows a haemorrhagic, well defined, left cerebellar lesion associated with mild surrounding oedema and no significant mass effect. No hydrocephalus. MRA and MRV unremarkable. 

Modality: CT

Findings:

CTB: Non-contrast axial images through the brain have been obtained. Comparison made to the previous MRI brain.

2.9 x 2.6 x 1.8 cm left cerebellar haemorrhage with surrounding vasogenic oedema. This exerts very mild mass effect upon the fourth ventricle. No hydrocephalus. No tonsillar or uncal herniation. No other intracranial haemorrhage. Grey-white matter differentiation is preserved with no evidence of acute ischaemia.

No calvarial fracture or suspicious bony abnormality seen. Imaged paranasal sinuses and mastoid air cells are clear.

CTA COW

The extracranial vessels, circle of Willis and vertebrobasilar system opacify normally with no aneurysm, vascular malformation, dissection or significant stenosis detected.

Vertebral arterial circulation demonstrates co-dominance. Aortic arch anatomy is conventional.

Degenerative changes of the cervical spine most marked at C5/6. No suspicious bone lesions. Lung apices clear. Conclusion

Large left cerebellar haemorrhage is stable in size compared to the MRI from 28/4/15. Very mild mass effect on the fourth ventricle. No hydrocephalus.

Normal CTA COW.

 

CT Brain

Modality: CT

The left cerebellar hemisphere haemorrhage has increased in size (2.6 to 4.2cm). There is associated mass-effect with effacement of the 4th ventricle or aqueduct, with associated mild hydrocephalus. There is no definite contrast enhancement in the lesion, but MRI with contrast is more sensitive for this purpose, particularly in the presence of intracranial haemorrhage. No other significant interval change.

Modality: CT

There is well-circumscribed 10.4 x 9.3 x 9.5 cm right adrenal mass, of soft tissue density, with internal calcification and dense linear bands internally. The mass displaces the IVC anteriorly, without evidence of invasion, and the right kidney is displaced inferiorly. Left adrenal is normal. No enlarged intra-abdominal or brachial lymph nodes.

Possibilities include primary adrenal tumour such as phaeochromocytoma and adrenal carcinoma, and metastasis. Adrenal adenoma would be unlikely to have this appearance.

Modality: Pathology

MICROSCOPIC DESCRIPTION: 1&2. The sections show fragments of cerebellar cortex and white matter. There is recent haemorrhage within white matter extending focally into cortex. Adjacent white matter shows prominent proliferation of small calibre vascular channels. These are lined by plump endothelial cells. There is oedema and reactive gliosis within intervening white matter. Several native blood vessels show thickening and hyalinisation of their walls. There is no evidence of active vasculitis. Within cerebellar white matter adjacent to the haemorrhage there is prominent infiltration by neutrophils. No organisms are identified. No evidence of tumour is seen. Immunostaining for A-beta protein is negative.

DIAGNOSIS: 1&2. Haematoma wall 1&2: Recent intracerebellar haemorrhage - see comment. COMMENT: The features in the specimens submitted, in particular the hyaline thickening of the walls of small native blood vessels, are most consistent with hypertensive intracerebellar haemorrhage. However, the presence of neutrophils within adjacent white matter raises the possibility of mycotic aneurysm.

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Case Information

rID: 37000
Case created: 21st May 2015
Last edited: 12th Dec 2015
Tag: rmh
Inclusion in quiz mode: Included

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