Cerebellar hemorrhage surgery

Cerebellar hemorrhage surgery

In 1906, Ballance first reported a surgical approach to treatment of cerebellar hemorrhage1) 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


Surgical treatment of cerebellar ICH can be life-saving but often leads to a poor functional outcome. New studies are needed on long-term functional outcome after a cerebellar ICH 6).

Since the 1970s, there has been a wide mutual consensus in the neurological and neurosurgical community that cerebellar ICHs should be operated on. However, the scientific proof is mainly based on small retrospective series with conflicting results 7).

To relieve brainstem compression and hydrocephalus, surgeons tend to favor occipital craniectomy or occipital craniotomy with hematoma evacuation in patients with a declining level of consciousness 8). Some regard this counterintuitive as long-term outcomes after surgical treatment of cerebellar ICH are generally pessimistic 9).

Since the report by Little et al., 10) the hematoma diameter has been considered a significant factor in the decision-making process for optimal treatment.

The criteria for surgery remain controversial, and many researchers have determined that a hematoma larger than 3 cm, obstruction of the quadrigeminal cistern, and compression of the fourth ventricle are surgical criteria 11) 12) 13).

Cohen et al. 14) used a maximal hematoma diameter greater than 3 cm as the surgical criterion, however, some patients with a hematoma larger than 3 cm who underwent conservative treatment had a good prognosis as well. In addition, a hematoma volume greater than 15 mL, being equivalent with a hematoma with a maximal diameter greater than 3 cm, has also been used as a criterion in some cases 15).

The criteria of Kobayashi et al., are as follows:

1) patients with Glasgow Coma Scale scores of 14 or 15 and with a hematoma of less than 40 mm in maximum diameter are treated conservatively

2) for the patients with Glasgow Coma Scale scores of 13 or less at admission or with a hematoma measuring 40 mm or more, hematoma evacuation with decompressive suboccipital craniectomy should be a treatment of choice

3) for the patient whose brain stem reflexes are entirely lost with flaccid tetraplegia or whose general condition is poor, intensive therapy is not indicated. The validity of these criteria was tested and confirmed in 49 cases 16).



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 ventriclewhich 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 17).



1) , 15)

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.

Kobayashi S, Sato A, Kageyama Y, et al. Treatment of Hypertensive Cerebellar Hemorrhage – Surgical or Conservative Management. Neurosurgery. 1994; 34:246–251

Heros RC. Surgical Treatment of Cerebellar Infarc- tion. Stroke. 1992; 23:937–938

Satopää J, Meretoja A, Koivunen RJ, Mustanoja S, Putaala J, Kaste M, Strbian D, Tatlisumak T, Niemelä MR. Treatment of intracerebellar haemorrhage: Poor outcome and high long-term mortality. Surg Neurol Int. 2017 Nov 9;8:272. doi: 10.4103/sni.sni_168_17. eCollection 2017. PubMed PMID: 29204307; PubMed Central PMCID: PMC5691556.

Witsch J, Neugebauer H, Zweckberger K, Jüttler E. Primary cerebellar haemorrhage: complications, treatment and outcome. Clin Neurol Neurosurg. 2013 Jul;115(7):863-9. doi: 10.1016/j.clineuro.2013.04.009. Epub 2013 May 6. Review. PubMed PMID: 23659765.

Wijdicks EF, St Louis EK, Atkinson JD, Li H. Clinician’s biases toward surgery in cerebellar hematomas: an analysis of decision-making in 94 patients. Cerebrovasc Dis. 2000 Mar-Apr;10(2):93-6. PubMed PMID: 10686446.

Luney MS, English SW, Longworth A, Simpson J, Gudibande S, Matta B, Burnstein RM, Veenith T. Acute Posterior Cranial Fossa Hemorrhage-Is Surgical Decompression Better than Expectant Medical Management? Neurocrit Care. 2016 Dec;25(3):365-370. PubMed PMID: 27071924; PubMed Central PMCID: PMC5138260.

Little JR, Tubman DE, Ethier R. Cerebellar hemorrhage in adults. Diagnosis by computerized tomography. J Neurosurg. 1978 Apr;48(4):575-9. PubMed PMID: 632882.
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Cohen ZR, Ram Z, Knoller N, Peles E, Hadani M. Management and outcome of non-traumatic cerebellar haemorrhage. Cerebrovasc Dis. 2002;14(3-4):207-13. PubMed PMID: 12403953.

Kirollos RW, Tyagi AK, Ross SA, van Hille PT, Marks PV. Management of spontaneous cerebellar hematomas: a prospective treatment protocol. Neurosurgery. 2001 Dec;49(6):1378-86; discussion 1386-7. PubMed PMID: 11846937.

Salvati M, Cervoni L, Raco A, Delfini R. Spontaneous cerebellar hemorrhage: clinical remarks on 50 cases. Surg Neurol. 2001 Mar;55(3):156-61; discussion 161. PubMed PMID: 11311913.

Kobayashi S, Sato A, Kageyama Y, Nakamura H, Watanabe Y, Yamaura A. Treatment of hypertensive cerebellar hemorrhage–surgical or conservative management? Neurosurgery. 1994 Feb;34(2):246-50; discussion 250-1. PubMed PMID: 8177384.

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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