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

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⁾.