Zebra sign: cerebellar bleeding pattern characteristic of cerebrospinal fluid loss

Abstract

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.

Remote Cerebellar Haemorrhage after Spinal Surgery

“…The abnormality seen on MR imaging is described as the 'Zebra sign' refers to the horizontal curvilinear configuration of the haemorrhage inbetween the cerebellar folia. 6 Other causes of cerebellar haemorrhage (e.g. hypertension, anticoagulation, aneurysms, vascular malformations or tumors) should be considered in the differential diagnosis.…”

Remote intracranial parenchymal haematomas as complications of spinal surgery: presentation of three cases with minor or untypical symptoms

“…The pattern of RCHs frequently differs from the mostly unilateral, compact feature of arterial bleedings. The typical bilateral bleedings, following the cerebellar folia, have been termed ''zebra sign'' [4].…”

Hematomas de cerebelo como complicación de drenaje lumbar: Presentación de dos casos y revisión de la literatura

“…Como exponen Brockmann et al 5 , parece existir un patrón característico de sangrado en los hematomas de cerebelo por pérdida de LCR. Primero, son sangrados de origen venoso, de localización en la parte superior del vermis y los surcos cerebelosos o folias, donde se localizan las venas puente del cerebelo.…”

“…Sin embargo, consideramos que, desde el punto de vista etiopatogénico, los casos que aquí presentamos guardan una estrecha relación con los demás casos de hematomas cerebelosos tras cirugía intracraneal y, sobre todo, intrarraquídea, al ser el drenaje de LCR el factor más probablemente involucrado. Así mismo, las características radiológicas de ambos casos son similares a las que describen Brockmann et al 5 relativamente frecuente tras la colocación de un DLE 24,28 . Clínicamente suele cursar con cefaleas, que típicamente se alivian con el decúbito, náuseas y vómitos, sin alteración del nivel de consciencia.…”