WHITE CEREBELLUM SIGN AS A DARK PROGNOSTIC INDICATOR OF CEREBRAL INJURY: A CASE REPORT

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O.A Badejo^1,2, E.C Nwafuluaku² , R.B Olatunji³ , J.A Balogun^1,2

1. Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan, Nigeria.
2. Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria.
3. Department of Radiology, College of Medicine, University of Ibadan/ University College Hospital, Ibadan, Nigeria.

Abstract

Introduction: The white cerebellum sign (WCS) is a classical but rare radiological finding usually associated with irreversible diffuse hypoxic-ischemic cerebral injury. Very few cases exist in the literature globally, especially from the West African region, as a potential hallmark of poor prognostic outcome. We describe the white cerebellum sign in a Nigerian pediatric patient, managed for severe head injury.

Case Presentation: A fourteen-year old boy presented to our emergency department with loss of consciousness following a pedestrian road traffic accident. Physical examination revealed a critically ill boy with fever, hypotension, tachycardia, gasping respiration, GCS 3, bilateral dilated unreactive pupils, absent corneal, gag and oculocephalic reflexes. He was thus diagnosed of severe traumatic brain injury and brainstem dysfunction. He had endotracheal intubation, ventilatory and inotropic support. Cranial computerized tomography scan of the patient
showed radiological features in keeping with the WCS. His clinical status remained poor until he suffered a cardiac arrest about twelve hours after admission.

Conclusion: WCS has been reported in relation to child abuse, anoxic-ischemic brain injury, inflammatory and metabolic brain disorders and trauma. It is a classical radiological description of diffuse cerebral edema alongside relatively normal cerebellar hemispheres and brainstem. Management of this pathology is symptomatic, and aims to ameliorate the associated raised intracranial pressure, control seizures and prevent cerebral infarction. The index patient, who presented 24 hours after severe head injury with associated early post-traumatic seizures, respiratory failure and brainstem dysfunction, had an unfavourable outcome consistent with previous reports of WCS. We have reported the rare but classical white cerebellum sign. It remains a grave prognosticator of cerebral injury and should be sought for in the neuroimaging of patients with acute brain insults.

Keywords: Hypoxic-Ischemic encephalopathy, Inversion sign, Pediatric head injury, Case report

Introduction

The white cerebellum sign is a characterization of relative hyperdensity of the cerebellar hemispheres and brainstem against a backdrop of diffuse hypodensity of the cerebrum, on cranial computerized tomography scan.^1-3 Very few cases exist in the literature globally, especially from the West African region as a potential hallmark of poor prognostic outcome. These have been reported mostly in association with hypoxicischemic encephalopathy and few ascribed to trauma.^{1- 4} Whereas the sign has been widely associated with irreversible brain damage, few cases of survival have been documented, with most of these having debilitating neurological sequaelae.^1,3-5 However, rare instances of good outcome have been reported by previous authors.³ Given that the cerebral edemainduced raised intracranial pressure is central to the resultant global cerebral ischemia, it stands to reason that early identification of this anomaly on neuroimaging and prompt institution of the appropriate therapy is crucial to the survival of the affected individuals and their long-term neurological status.

We describe the white cerebellum sign in a fourteen year-old Nigerian boy, who was managed for severe head injury in a resource poor neurosurgical facility. The authors hope to bring more awareness to this rare poor prognostic indicator of brain injury to clinicians. This case report has been written in accordance with the CARE guidelines.⁶