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Cerebellar Hemorrhage Treatment & Management

  • Author: J Stephen Huff, MD, FACEP; Chief Editor: Helmi L Lutsep, MD  more...
 
Updated: Apr 23, 2014
 

Medical Care

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  • Surgical care has been the mainstay of therapy for CH, although some patients with small hematomas may be treated successfully without surgery. There has been a call for large prospective randomized controlled trials to determine best treatment.[4]
    • Recent efforts have focused on improving patient selection for surgery, both in identifying patients who are candidates for nonsurgical management and identifying those in whom intensive therapy is likely to be futile.
    • Variation in patient selection for surgery is common, and only general guidelines are outlined here. Consultation with a neurosurgeon is indicated for all patients.
  • Most investigators agree that a patient who is awake and has a Glasgow coma scale score of 14 or greater (some investigators say 9 or greater) with a small hemorrhage (some investigators say < 30 mm diameter, others < 40 mm diameter) without hydrocephalus may be a candidate for conservative supportive care with close monitoring. (See the Glasgow Coma Scale calculator.)
    • If the patient's condition deteriorates, re-evaluate and reconsider surgery.
    • Clot location (medial or lateral) is also a factor in patient selection for surgery.
    • Almost all agree that a patient who is comatose, flaccid, and without brainstem reflexes with a large midline hemorrhage has a poor prognosis. For such patients, supportive care without surgery may be the only indicated therapy.
    • However, clear consensus does not exist regarding many patients who fall between these extremes. Variation in surgical treatment exists even within a geographic region.
  • Immediate management consists of stabilization and resuscitation.
    • Oxygen supplementation may be indicated.
      • Perform endotracheal intubation if required for airway management in patients with a decreased level of consciousness.
      • Use rapid sequence technique with precautions for increased intracranial pressure (ICP).
    • Correct fluid deficit with isotonic saline.
    • Mannitol 1 g/kg may be considered preoperatively in patients with tight posterior fossa.
    • Persistent hypertension (mean arterial pressure >130 mm Hg) may indicate judicious use of labetalol or another titratable antihypertensive agent.
    • In symptomatic bradycardia reflecting Cushing response, atropine (0.5-1 mg) may be beneficial if hypotension is present.
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Surgical Care

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  • Indications for surgery remain controversial.[5]
  • Ventriculostomy may be indicated in patients with hemorrhage and hydrocephalus but is controversial as well.[5]
  • Suboccipital craniotomy with clot evacuation is indicated in patients with altered level of consciousness and a large clot (see discussion in Medical Care; clot size >30-40 mm in greatest diameter).
  • American Heart Association/American Stroke Association guidelines previously gave a high-level recommendation for surgical removal of hematoma smaller than 30 mm in patients who are deteriorating neurologically or have brain stem compression and/or hydrocephalus from ventricular obstruction,[6, 7] but a specific size recommendation is lacking in more recent recommendations.[5, 7]
  • Patients with a large central clot and absent brainstem reflexes have a poor prognosis. In these cases, some advocate supportive therapy only.
  • Patients may appear to be in stable condition but can worsen suddenly. St Louis et al list clinical and CT findings that may identify patients who are at risk for deterioration.[8]
    • Admission systolic blood pressure greater than 200 mm Hg
    • Pinpoint pupils and abnormal corneal and oculocephalic reflexes
    • Hemorrhage extending into the cerebellar vermis
    • Hematoma diameter greater than 30 mm
    • Brainstem distortion
    • Intraventricular hemorrhage
    • Upward herniation
    • Acute hydrocephalus
  • Clot evacuation and direct fibrinolysis of the hematoma has been reported in small numbers of carefully selected patients.[9, 10, 11, 12]
  • Endoscopic hematoma evacuation has also been reported to have been effective in a small number of patients.
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Consultations

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  • Consult neurosurgery for all patients, even those who are candidates for conservative management. Sudden deterioration may require neurosurgical intervention.
  • After the clinical condition stabilizes, physical therapy, speech therapy, and occupational therapy may be helpful.
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Contributor Information and Disclosures
Author

J Stephen Huff, MD, FACEP Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD, FACEP is a member of the following medical societies: American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center

Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Neurological Association, American Society of Neurorehabilitation, American Academy of Neurology, American Heart Association, American Medical Association, National Stroke Association, Phi Beta Kappa, Tennessee Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2.

Additional Contributors

Draga Jichici, MD, FRCP, FAHA Associate Clinical Professor, Department of Neurology and Critical Care Medicine, McMaster University School of Medicine, Canada

Draga Jichici, MD, FRCP, FAHA is a member of the following medical societies: American Academy of Neurology, Royal College of Physicians and Surgeons of Canada, Canadian Medical Protective Association, Canadian Medical Protective Association, Neurocritical Care Society, Canadian Critical Care Society, Canadian Critical Care Society, Canadian Neurocritical Care Society, Canadian Neurological Sciences Federation

Disclosure: Nothing to disclose.

References
  1. Brockmann MA, Groden C. Remote cerebellar hemorrhage: a review. Cerebellum. 2006. 5(1):64-8. [Medline].

  2. Konya D, Ozgen S, Pamir MN. Cerebellar hemorrhage after spinal surgery: case report and review of the literature. Eur Spine J. 2006 Jan. 15(1):95-9. [Medline].

  3. Young YR, Lee CC, Sheu BF, Chang SS. Neurogenic cardiopulmonary complications associated with spontaneous cerebellar hemorrhage. Neurocrit Care. 2007. 7(3):238-40. [Medline].

  4. Witsch J, Neugebauer H, Zweckberger K, Jüttler E. Primary cerebellar haemorrhage: complications, treatment and outcome. Clin Neurol Neurosurg. 2013 Jul. 115(7):863-9. [Medline].

  5. Amar AP. Controversies in the neurosurgical management of cerebellar hemorrhage and infarction. Neurosurg Focus. 2012 Apr. 32(4):E1. [Medline].

  6. [Guideline] Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007 Jun. 38(6):2001-23. [Medline].

  7. [Guideline] Morgenstern LB, Hemphill JC 3rd, Anderson C, Becker K, Broderick JP, Connolly ES Jr, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010 Sep. 41(9):2108-29. [Medline].

  8. St Louis EK, Wijdicks EF, Li H. Predicting neurologic deterioration in patients with cerebellar hematomas. Neurology. 1998 Nov. 51(5):1364-9. [Medline].

  9. Mohadjer M, Eggert R, May J, Mayfrank L. CT-guided stereotactic fibrinolysis of spontaneous and hypertensive cerebellar hemorrhage: long-term results. J Neurosurg. 1990 Aug. 73(2):217-22. [Medline].

  10. Yamamoto T, Nakao Y, Mori K. Endoscopic hematoma evacuation for hypertensive cerebellar hemorrhage. Minim Invasive Neurosurg. 2006 Jun. 49(3):173-8. [Medline].

  11. Deininger MH, Adam A, Van Velthoven V. Free-hand bedside catheter evacuation of cerebellar hemorrhage. Minim Invasive Neurosurg. 2008 Feb. 51(1):57-60. [Medline].

  12. Neugebauer H, Witsch J, Zweckberger K, Jüttler E. Space-occupying cerebellar infarction: complications, treatment, and outcome. Neurosurg Focus. 2013 May. 34(5):E8. [Medline].

  13. Andrews CM, Jauch EC, Hemphill JC 3rd, Smith WS, Weingart SD. Emergency neurological life support: intracerebral hemorrhage. Neurocrit Care. 2012 Sep. 17 Suppl 1:S37-46. [Medline].

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Large hemorrhage of cerebellar vermis.
 
 
 
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