cerebellar_hemorrhage_surgery

Cerebellar hemorrhage surgery

In 1906, Ballance first reported a surgical approach to treatment of cerebellar hemorrhages 1) 2).

Since then, surgical treatment has become the general option for treatment 3).

Recommendations from Kobayashi et al in 1994 4)

1. patients with a Glasgow Coma Scale (GCS) score ≥14 and hematoma <4 cm diameter: treat conservatively

2. patients with GCS≤13 or with a hematoma ≥4 cm: surgical evacuation.

3. patients with absent brain stem reflexes and flaccid quadriplegia: intensive therapy is not indi- cated. Note: some authors contend that the loss of brain stem reflexes from direct compression may not be irreversible, 5) and that cerebellar hemorrhage represents a surgical emergency (and that the above criteria would thus deny potentially helpful surgery to some, see discussion of cerebellar infarction and decompression.

4. patients with hydrocephalus: ventricular catheter (if no coagulopathy). Caution: do not overdrain to avoid upward cerebellar herniation. Most cases with hydrocephalus also require evacuation of the clot

Indications

Cerebellar hemorrhage surgery indications.

Technique

Position

Lateral oblique position with the involved side up.

If rapidity is crucial a suboccipital midline skin incision is preferred because it can be taken down quickly with little fear of encountering a vertebral artery.

Suboccipital craniectomy is preferred over suboccipital craniotomy to accomodate postoperative swelling.

A prophylactically ventriculostomy at Frazier's point is recommended to allow rapid treatment of postoperative hydrocephalus or intracranial pressure monitoring.

In cases where there has been rupture into the ventricular system, the surgical microscope should be used to follow the clot to the fourth ventricle which is then cleared of clot.

External ventricular drainage (EVD) combined with intraventricular thrombolysis (IVF) is rarely used in severe spontaneous cerebellar hemorrhage (SCH) with intraventricular hemorrhage (IVH).

It is a treatment option for elderly patients with severe SCH + IVH 6).

Video

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References

1)
Cho SM, Hu C, Pyen JS, Whang K, Kim HJ, Han YP, et al. Predictors of outcome of spontaneous cerebellar hemorrhage. J Korean Neurosurg Soc. 1997 Oct;26(10):1395–1400.
2) , 3)
Dahdaleh NS, Dlouhy BJ, Viljoen SV, Capuano AW, Kung DK, Torner JC, Hasan DM, Howard MA 3rd. Clinical and radiographic predictors of neurological outcome following posterior fossa decompression for spontaneous cerebellar hemorrhage. J Clin Neurosci. 2012 Sep;19(9):1236-41. doi: 10.1016/j.jocn.2011.11.025. Epub 2012 Jun 20. PubMed PMID: 22721890.
4)
Kobayashi S, Sato A, Kageyama Y, et al. Treatment of Hypertensive Cerebellar Hemorrhage - Surgical or Conservative Management. Neurosurgery. 1994; 34:246–251
5)
Heros RC. Surgical Treatment of Cerebellar Infarc- tion. Stroke. 1992; 23:937–938
6)
Zhang J, Wang L, Xiong Z, Han Q, Du Q, Sun S, Wang Y, You C, Chen J. A treatment option for severe cerebellar hemorrhage with ventricular extension in elderly patients: intraventricular fibrinolysis. J Neurol. 2014 Feb;261(2):324-9. doi: 10.1007/s00415-013-7198-2. Epub 2013 Dec 3. PubMed PMID: 24297364.
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