Numbers
- Nontraumatic cerebellar hemorrhage affects approximately 10 000 patients in the United states each year
- Accounts for
- 10% of all ICHs
- 1.5% of all strokes.
- Surgical evacuation
- Kuramatsu et al 2019
- >12cm3 increase survival below this size increase poorer functional outcome
- GCS ≤ 13 or with hematoma size ≥ 4 cm
- Most cases with hydrocephalus also require evacuation of the hematoma.
- Presence of “tight posterior fossa” (TPF)
- Consist of:
- Obliteration of the basal cisterns of the posterior cranial fossa
- Enlargement of the third ventricle, lateral ventricles, and temporal horns
- Effacement of the fourth ventricle
- The TPF does not only depend on the size of the hematoma.
- A hematoma of similar size may exert widely different amounts of compression influenced by several factors such as patient’s age, the amount of cerebellar atrophy, and the anatomy of the posterior fossa. Based on the TPF concept, the critical size for hematoma evacuation can be reduced to 5–10 mm from 3 cm
- EVD only
- EVD then posterior fossa craniectomy and clot evacuation
- Duroplasty or leave the dura open
- Initial steps
- After you open the dura, you observe a very swollen and tight cerebellum.
- Elevate the patient’s head to above 30 degrees.
- Check neck positioning for obstruction of venous return and readjust as necessary.
- Hyperventilate to a PCO2 of 30 to 35 mm Hg.
- Hypertonic saline
- Ensure adequate sedation and pharmacologic muscle paralysis.
- Decompress the hematoma rapidly.
- Drain some CSF by EVD.
- Open the cisterna magna and drain some more CSF.
- One may need to resect parts of the cerebellar hemisphere.
- Ensure that the foramen magnum is open.
- If the swelling is still uncontrollable, then consider the following causes:
- Intraparenchymal hematoma in a different location
- Contralateral or supratentorial subdural or epidural hematoma
- Cytotoxic edema from trauma
- Venous infarction
- 2nd tier steps
- Duraplasty and quick closure
- Leaving the bone flap out (craniectomy)
- Obtaining an emergent CT scan of the head and considering going back to the operating room for further exploration.
Indication
Options
Pearls
- Outcomes
- Kuramatsu et al 2019
- Retrospective study matched using propensity score analysis
- 152 surgical clot evacuation
- 152 no clot evacuation
- Outcome
- Significantly higher 3-month survival among patients who underwent surgical hematoma evacuation (78.3% vs 61.2%),
- There was no significant difference proportion of patients with favourable functional outcome at 3 or 12 months
- A hematoma volume cut point of 12 to 15 cm3 was identified;
- Below this level, surgical hematoma evacuation was associated with a reduced likelihood of favourable outcome (30.6%vs 62.3%).
- Above this increase likelihood of survival 74.5% vs 45.1%
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