Dense cerebellum sign

Case contributed by Dr Jan Frank Gerstenmaier


This patient with a history of alcoholic liver disease was admitted to the ED with a clinical stroke.

Patient Data

Age: 57
Gender: Male

Admission CT

No evidence of acute hemorrhage or large cortical territorial infarction. There is some cerebral atrophy and an old right frontal lobe insult, along with some white matter changes typical for mild small vessel chronic ischemia.

The patient was commenced on aspirin for presumed stroke. While awaiting an MRI brain to confirm, the patient deteriorated with more pronounced signs of stroke. He then suffered a respiratory arrest.


CT following respiratory arrest

36h post admission CT

There is acute hemorrhage in the posterior cranial fossa involving the pons and cerebellum, extending into the fourth ventricle.

Supratentorially, there is severe mass effect with midline shift to the right and sulcal effacement. Although there is obstructive hydrocephalous, the left lateral ventricle is completely compressed - There is hypoattenuation and tumefaction of the left MCA and ACA territories with subfacine herniation.

The cerebellum appears of increased density against the hypoattenuating cerebrum.

Case Discussion

The appearances were considered incompatible with survival. 

The exact sequence of events is unclear, but the respiratory arrest has likely resulted from the brainstem herniation, with associated Duret hemorrhage. ACA infarction is a recognized sequelae of subfalcine herniation causing ACA compression.

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Case information

rID: 22747
Published: 20th Apr 2013
Last edited: 16th Jul 2018
Tag: signs
Inclusion in quiz mode: Included

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