Prognostic factors in the treatment of cerebellar haemorrhage

Abstract

A prospective study for the treatment of cerebellar haemorrhage was conducted in a non-selected group of 33 patients. All patients with cerebellar haemorrhage arriving at the Department of Neurosurgery at Homburg/Saar have been included in this study, also those in bad condition, with high risk factors, and the aged. All of them required intensive care respectively intensive supervision. The following management protocol has been established. I. Cases with small haemorrhage, in good clinical condition, without hydrocephalus and/or occlusion of the basal cisterns: intensive supervision, operative intervention only if they deteriorate into one of the following groups. II. Cases with hydrocephalus-even if not yet pronounced-but without occluded basal cisterns and without major tonsillar herniation: pressure monitored ventricular drainage, which opens at 15 mm Hg and thus prevents higher CSF pressure developing. III. a): Cases with large haematoma, occluded basal cisterns and/or tonsillar herniation, but without severe general risk factors, as a first step: pressure monitored ventricular drainage; as a second step, if they do not improve soon after the normalization of the ventricular pressure: open surgical evacuation of the haematoma, which also decompresses the posterior fossa. If present and possible, causative vascular malformations may be dealt with at the same session. III. b): Same intracranial situation, but patients with severe general risk factors: pressure monitored ventricular drainage only. IV. Cases with causative aneurysm or angioma, who initially had been treated conservatively or by ventricular drainage: secondary operation of the vascular malformation after stabilization of the general conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

Controversies in the neurosurgical management of cerebellar hemorrhage and infarction

“…6,17 For instance, in the series of Ott et al, 25 the mortality rate was 17% for patients who were conscious at the time of surgery and 75% for those who were unconscious. Similarly, in the series of Donauer et al, 7 patients presenting with GCS scores less than 6 had a 60% mortality rate and Karnofsky Outcome Index total of 26, while those with GCS scores greater than 10 had only a 20% mortality rate and a Karnofsky Outcome Index total of 66. In the series of Kobayashi et al, 18 of the 5 patients with GCS scores of 4, 3 died and 2 remained vegetative despite surgery.…”

“…7,17,18,26,29 In this algorithm, decompression of the brainstem follows only if the patient does not improve with relief of the hydrocephalus.…”

“…4,26,29 Conventional neurosurgical training advises drainage at no less than 15-20 mm Hg above the level of the third ventricle. 7 These debates began in the pre-CT era, when attribution of the underlying cause of clinical deterioration (hydrocephalus vs brainstem compression) was left to clinical examination alone. In 1960, McKissock et al 22 reported 34 cases of cerebellar hemorrhage.…”

“…Collectively, however, these reports suggest that the benefit of surgery is not so straightforward. Donauer et al 7 reviewed 21 papers from 1958 to 1993 and performed a meta-analysis comparing medical versus operative treatment of cerebellar ICH. In the cohort of 357 patients who underwent surgery, the mortality rate was 49%, while that in the 269 patients treated conservatively was 50%.…”

“…When deterioration occurs, mortality has been reported to be high (25%-100%), regardless of treatment. 1,7,17,18,30 Deterioration can occur unpredictably, even in patients who appear to have reached a clinical plateau. 11,17 Ott et al 25 reported that 50% of patients who remained alert and relatively stable for 2 days degenerated into coma over the course of the next several days, and a disconcerting 25% of patients who remained awake for 7 days subsequently deteriorated.…”