Cerebellar hemorrhage

Case contributed by RMH Neuropathology


10 days of headache, diplopia, and left cerebellar signs.

Patient Data

Age: 50 years
Gender: Male

MRI Brain


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



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 hemorrhage with surrounding vasogenic edema. This exerts very mild mass effect upon the fourth ventricle. No hydrocephalus. No tonsillar or uncal herniation. No other intracranial hemorrhage. Grey-white matter differentiation is preserved with no evidence of acute ischemia.

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


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 hemorrhage 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


The left cerebellar hemisphere hemorrhage 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 hemorrhage. No other significant interval change.


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 tumor such as pheochromocytoma and adrenal carcinoma, and metastasis. Adrenal adenoma would be unlikely to have this appearance.


MICROSCOPIC DESCRIPTION: 1&2. The sections show fragments of cerebellar cortex and white matter. There is recent hemorrhage within white matter extending focally into cortex. Adjacent white matter shows prominent proliferation of small caliber vascular channels. These are lined by plump endothelial cells. There is edema 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 hemorrhage there is prominent infiltration by neutrophils. No organisms are identified. No evidence of tumor is seen. Immunostaining for A-beta protein is negative.

DIAGNOSIS: 1&2. Hematoma wall 1&2: Recent intracerebellar hemorrhage - 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 hemorrhage. However, the presence of neutrophils within adjacent white matter raises the possibility of mycotic aneurysm.

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