Remote cerebellar hemorrhage (zebra sign) in vascular neurosurgery: pathophysiological insights

Neurol Med Chir (Tokyo). 2009 Jun;49(6):229-33; discussion 233-4. doi: 10.2176/nmc.49.229.

Abstract

Hemorrhage in regions remote from the site of initial intracranial operations is rare, but may be fatal. Postoperative cerebellar hemorrhage as a complication of supratentorial surgery, with a radiological appearance known as zebra sign, is an increasingly recognized clinical entity and is associated mainly with vascular neurosurgery or temporal lobe resection. The pathophysiology remains unclear. Three cases of remote cerebellar hematoma occurred after neck clipping of anterior communicating artery aneurysms. All patients had similar clinical findings and underwent pterional craniotomy with the head in accentuated extension. One patient died and the two were discharged without symptoms. Cerebellar hemorrhage probably has a multifactorial origin involving positioning associated with abundant cerebrospinal fluid drainage causing cerebellar sag with resultant vein stretching and bleeding, and use of aspirin or other antiplatelet agents.

Publication types

  • Case Reports

MeSH terms

  • Aged
  • Cerebellar Diseases / etiology
  • Cerebellar Diseases / physiopathology
  • Cerebellum / blood supply
  • Cerebellum / pathology
  • Cerebellum / physiopathology*
  • Cerebral Angiography
  • Cerebral Veins / diagnostic imaging
  • Cerebral Veins / pathology
  • Cerebral Veins / physiopathology
  • Craniotomy / adverse effects
  • Fatal Outcome
  • Female
  • Humans
  • Hypotension, Orthostatic / complications
  • Hypotension, Orthostatic / physiopathology
  • Iatrogenic Disease
  • Intracranial Aneurysm / diagnostic imaging
  • Intracranial Aneurysm / pathology
  • Intracranial Aneurysm / surgery
  • Intracranial Hemorrhage, Hypertensive / diagnostic imaging
  • Intracranial Hemorrhage, Hypertensive / etiology
  • Intracranial Hemorrhage, Hypertensive / physiopathology
  • Intracranial Hemorrhages / diagnostic imaging
  • Intracranial Hemorrhages / etiology*
  • Intracranial Hemorrhages / physiopathology*
  • Intracranial Hypotension / complications
  • Intracranial Hypotension / physiopathology
  • Intraoperative Care / adverse effects
  • Middle Aged
  • Neurosurgical Procedures / adverse effects*
  • Platelet Aggregation Inhibitors / adverse effects
  • Postoperative Hemorrhage / etiology*
  • Postoperative Hemorrhage / physiopathology*
  • Tomography, X-Ray Computed
  • Vascular Surgical Procedures / adverse effects
  • Ventriculostomy / adverse effects

Substances

  • Platelet Aggregation Inhibitors