Zebra sign: cerebellar bleeding pattern characteristic of cerebrospinal fluid loss

Case report

Restricted access

✓ Supratentorial subdural hematoma is a well-known complication following spinal interventions. Less often, spinal or supratentorial interventions cause remote cerebellar hemorrhage (RCH). The exact pathomechanism accounting for RCH remains unclear, but an interventional or postinterventional loss of cerebrospinal fluid (CSF) seems to be involved in almost all cases. Hemorrhage is often characterized by a typical, streaky bleeding pattern due to blood spreading in the cerebellar sulci. Three different cases featuring this bleeding pattern following spinal, supratentorial, and thoracic surgery are presented. Possible pathomechanisms leading to RCH are discussed. Based on data from the underlying cases and the reviewed literature, the authors concluded that this zebra-pattern hemorrhage seems to be typical in a postoperative loss of CSF, which should always be considered on presentation of this bleeding pattern.

Article Information

Address reprint requests to: Marc A. Brockmann, M.D., Department of Neuroradiology, University Hospital Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany. email: brockmann@gmx.de.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Case 1. Left: Axial CT scan obtained 4 hours after lumbar surgery involving fusion of L5—S1, revealing a streaky, curvilinear bleeding pattern with blood in the cerebellar sulci facing the tentorium. Right: Axial CT scan demonstrating another small hemorrhage in the frontal interhemispheric fissure, also interpreted as being related to the acute loss of spinal CSF.

  • View in gallery

    Case 2. Left and Right: Axial CT scans obtained 2 hours after resection of a large left-sided sphenoidal meningioma. The zebra pattern of the RCH again is located in the upper sulci of the cerebellum.

  • View in gallery

    Case 3. Upper: Axial CT scans obtained in a patient who underwent resection of a Pancoast tumor, displaying RCH with blood in the cerebellar sulci facing the tentorium. Lower: Axial CT scans obtained 3 days later, exhibiting pronounced pneumocephalus. Repeated thoracotomy revealed avulsion of the second left thoracic root.



Anonymous: Editorial: lumbar puncture. Br Med J 1:31975Anonymous: Editorial: lumbar puncture. Br Med J 1:


Alemohammad SBouzarth WF: Intracranial subdural hematoma following lumbar myelography. Case report. J Neurosurg 52:2562581980J Neurosurg 52:


Andrews RTKoci TM: Cerebellar herniation and infarction as a complication of an occult postoperative lumbar dural defect. AJNR 16:131213151995AJNR 16:


Benzon HT: Intracerebral hemorrhage after dural puncture and epidural blood patch: nonpostural and noncontinuous headache. Anesthesiology 60:2582591984Benzon HT: Intracerebral hemorrhage after dural puncture and epidural blood patch: nonpostural and noncontinuous headache. Anesthesiology 60:


Bloch JRegli L: Brain stem and cerebellar dysfunction after lumbar spinal fluid drainage: case report. J Neurol Neurosurg Psychiatry 74:9929942003J Neurol Neurosurg Psychiatry 74:


Brisman MHBederson JBSen CNGermano IMMoore FPost KD: Intracerebral hemorrhage occurring remote from the craniotomy site. Neurosurgery 39:111411221996Neurosurgery 39:


Chumas PDDrake JMDel Bigio MR: Death from chronic tonsillar herniation in a patient with lumboperitoneal shunt and Crouzon's disease. Br J Neurosurg 6:5955991992Br J Neurosurg 6:


Cloft HJMatsumoto JALanzino GCail WS: Posterior fossa hemorrhage after supratentorial surgery. AJNR 18:157315801997AJNR 18:


Dan NG: Intracranial subdural haematoma after metrizamide myelography. Med J Aust 140:2892901984Dan NG: Intracranial subdural haematoma after metrizamide myelography. Med J Aust 140:


de Noronha RJSharrack BHadjivassiliou MRomanowski CA: Subdural haematoma: a potentially serious consequence of spontaneous intracranial hypotension. J Neurol Neurosurg Psychiatry 74:7527552003J Neurol Neurosurg Psychiatry 74:


Friedman JAEcker RDPiepgras DGDuke DA: Cerebellar hemorrhage after spinal surgery: report of two cases and literature review. Neurosurgery 50:136113642002Neurosurgery 50:


Friedman JAPiepgras DG: Remote hemorrhage. J Neurosurg Spine 95:2792802001J Neurosurg Spine 95:


Gehri RZanetti MBoos N: Subacute subdural haematoma complicating lumbar microdiscectomy. J Bone Joint Surg (Br) 82:104210452000J Bone Joint Surg (Br) 82:


Gelfenbeyn MVasil'ev SKrylov V: Cerebellar haemorrhage after supratentorial aneurysm surgery with lumbar drainage. Neurosurg Rev 24:2142192001Neurosurg Rev 24:


Glass PMKennedy WF Jr: Headache following subarachnoid puncture. Treatment with epidural blood patch. JAMA 219:2032041972JAMA 219:


Hart IKBone IHadley DM: Development of neurological problems after lumbar puncture. Br Med J 296:51521988Br Med J 296:


Heiss ENeubauer U: Akutes subdurales hematom nach lumbaler myelographie. ROFO 135:7357361981ROFO 135:


Hentschel SJRhines LDWong FCGokaslan ZLMcCutcheon IE: Subarachnoid-pleural fistula after resection of thoracic tumors. J Neurosurg Spine 100:3323362004J Neurosurg Spine 100:


Honegger JZentner JSpreer JCarmona HSchulze-Bonhage A: Cerebellar hemorrhage arising postoperatively as a complication of supratentorial surgery: a retrospective study. J Neurosurg 96:2482542002J Neurosurg 96:


Jensen JT: Epidural placement of Pantopaque after myelography. Neuroradiology 5:1972011973Jensen JT: Epidural placement of Pantopaque after myelography. Neuroradiology 5:


Kaplan SSLauryssen C: Cerebellar haemorrhage after evacuation of an acute supratentorial subdural haematoma. Br J Neurosurg 13:3293311999Br J Neurosurg 13:


Koller MOrtler MLangmayr JTwerdy K: Posterior-fossa haemorrhage after supratentorial surgery—report of three cases and review of the literature. Acta Neurochir 141:5875921999Acta Neurochir 141:


Konig ALaas RHerrmann HD: Cerebellar haemorrhage as a complication after supratentorial craniotomy. Acta Neurochir 88:1041081987Acta Neurochir 88:


Levine MCWhite DW: Chronic postmyelographic headache. A result of persistent epidural cerebrospinal fluid fistula. JAMA 229:6846851974JAMA 229:


Madow L: Pontine hemorrhage following cranial surgery for supratentorial tumor. Arch Neurol 2:62731960Madow L: Pontine hemorrhage following cranial surgery for supratentorial tumor. Arch Neurol 2:


Megele R: Kraniales subdural hematom nach Myelographie. Dtsch Med Wochenschr 111:182018221986Megele R: Kraniales subdural hematom nach Myelographie. Dtsch Med Wochenschr 111:


Modesti LMHodge CJBarnwell ML: Intracerebral hematoma after evacuation of chronic extracerebral fluid collections. Neurosurgery 10:6896931982Neurosurgery 10:


Morandi XRiffaud LCarsin-Nicol BGuegan Y: Intracerebral hemorrhage complicating cervical “hourglass” schwannoma removal. Case report. J Neurosurg Spine 94:1501532001J Neurosurg Spine 94:


Papanastassiou VKerr RAdams C: Contralateral cerebellar hemorrhagic infarction after pterional craniotomy: report of five cases and review of the literature. Neurosurgery 39:8418521996Neurosurgery 39:


Poppen JLKendrick JF JrHicks SF: Brain stem hemorrhages secondary to supratentorial space-taking lesions. J Neuropathol Exp Neurol 11:2672791952J Neuropathol Exp Neurol 11:


Suess OStendel RBaur SSchilling ABrock M: Intracranial haemorrhage following lumbar myelography: case report and review of the literature. Neuroradiology 42:2112142000Neuroradiology 42:


Toczek MTMorrell MJSilverberg GALowe GM: Cerebellar hemorrhage complicating temporal lobectomy. Report of four cases. J Neurosurg 85:7187221996J Neurosurg 85:


van Calenbergh FGoffin JPlets C: Cerebellar hemorrhage complicating supratentorial craniotomy: report of two cases. Surg Neurol 40:3363381993Surg Neurol 40:


Waga SShimosaka SSakakura M: Intracerebral hemorrhage remote from the site of the initial neurosurgical procedure. Neurosurgery 13:6626651983Neurosurgery 13:


Yaşargil MGYonekawa Y: Results of microsurgical extra-intracranial arterial bypass in the treatment of cerebral ischemia. Neurosurgery 1:22241977Neurosurgery 1:


Yoshida SYonekawa YYamashita KIhara IMarooka Y: Cerebellar hemorrhage after supratentorial craniotomy—report of three cases. Neurol Med Chir 30:7387431990Neurol Med Chir 30:


Cited By



All Time Past Year Past 30 Days
Abstract Views 11 11 11
Full Text Views 121 121 28
PDF Downloads 56 56 9
EPUB Downloads 0 0 0


Google Scholar