Zebra sign: cerebellar bleeding pattern characteristic of cerebrospinal fluid loss

Case report

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✓ 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.

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Figures

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    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.

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    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.

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    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.

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