We present the clinical case of a 41-year-old woman with no history of interest, except for arterial hypertension, who presented at home with a sudden episode of severe headache in the occipital region, accompanied by a progressive decrease in the level of consciousness. She had presented similar episodes of headache in the previous week, although of lesser intensity, which subsided with anti-inflammatory drugs.
The emergency services attended her at home, where orotracheal intubation was performed due to a low level of consciousness. She was transferred urgently to a hospital with neurosurgical services. On admission, a simple cranial computed tomography (CT) scan showed a right cerebellar intraparenchymal haemorrhage with a volume greater than 4 cm3, with discrete oedema and obliteration of the IV ventricle. It was decided to evacuate the haematoma and place an external ventricular drain. After surgery, he was admitted to the Intensive Care Unit (ICU). He underwent deferred CT angiography and cerebral arteriography with no obvious vascular anomalies.

During his stay in the ICU, he had a torpid evolution due to intracranial hypertension during the first few days. After withdrawal of sedation, he awoke with an adequate level of consciousness and 48 hours later he was conscious; the neurological examination revealed nystagmus in all directions, bilateral facial paralysis, predominantly right tetraparesis, left dysmetria and predominantly right hyporeflexia with right extensor plantar cutaneous reflex.
On the eighth day of her admission to the ICU, she was extubated in the morning and remained eupneic throughout the day with a normal ventilatory pattern. That same night she began to experience hypoventilation which led to severe respiratory acidosis and secondary respiratory arrest requiring intubation and MV.
Given the clinical suspicion of respiratory centre involvement, magnetic resonance imaging (MRI) of the brainstem was performed, showing changes secondary to the evacuation of the right cerebellar haematoma and revealing lesions in the bulb and pons, which had not been seen in the previous control CT scan. It was decided to perform a percutaneous tracheostomy for invasive mechanical ventilation (IMV), which she required mainly at night. Finally, she was discharged to the ward where it was possible to close the tracheostoma and she continued with non-invasive mechanical ventilation (NIV) with nasobuccal mask.