An 81 yo female presents with acute onset AMS approximately one hour ago. No known history of trauma.  Pt reports she doesn't feel well and wants to be left alone to sleep.  She is oriented x3 with very poor effort on neuro exam. She moves all extremities and has no facial droop and no pronator drift. Per EMR pt takes warfarin for hx of a-fib.  CT head is shown below.  What's the diagnosis?  Scroll down for answer.

Answer:  Cerebellar Hemorrhage

Risk factors: HTN, older age, anticoagulation, excessive ETOH

Symptoms: dizziness/vertigo, nausea and vomiting, gait instability, headache, limb ataxia, dysarthria, nystagmus, and cranial nerve abnormalities

Treatment: 

• BP management - goal <180 SBP; no advantage for aggressive BP lowering per INTERACT-2 trial (click here for quick reference on BP managment of neurological emergencies)
• Surgical decompression ASAP (>3cm, neurological deterioration, brainstem compression, hydrocephalus)
• Reversal of anticoagulation (warfarin - vitamin K and PCC favored over FFP (PCC requires less volume and evidence suggests it is faster)

References:

Go S, Worman DJ. Stroke Syndromes. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds.Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016.

Rordorf G, McDonald C.  ‘Spontaneous intracerebral hemorrhage: Treatment and prognosis.” UpToDate, Inc. Nov 2018

Rordorf G, McDonald C. “Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis.” UpToDate, Inc. Nov 2018