eMedicine Specialties > Neurology > Neurological Emergencies

Cerebellar Hemorrhage: Treatment & Medication

Author: J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
Contributor Information and Disclosures

Updated: Dec 11, 2008

Treatment

Medical Care

  • Surgical care has been the mainstay of therapy for CH, although some patients with small hematomas may be treated successfully without surgery.
    • 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.
    • 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.

Surgical Care

  • Indications for surgery are controversial.
  • Ventriculostomy is indicated in patients with hemorrhage and hydrocephalus.
  • 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).
  • 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.4
    • 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.5,6,7
  • Endoscopic hematoma evacuation has also been reported to have been effective in a small number of patients.

Consultations

  • 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.

Medication

No specific drug therapy exists for CH. Medications useful in treating hypertension (eg, labetalol) and increased ICP (eg, mannitol) may have a limited role in the acute phase. See the article Intracranial Hemorrhage for details.

Patients with an identified coagulopathy may require fresh frozen plasma or other products that are specific for the coagulopathy.

More on Cerebellar Hemorrhage

Overview: Cerebellar Hemorrhage
Differential Diagnoses & Workup: Cerebellar Hemorrhage
Treatment & Medication: Cerebellar Hemorrhage
Follow-up: Cerebellar Hemorrhage
Multimedia: Cerebellar Hemorrhage
References
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References

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  2. Konya D, Ozgen S, Pamir MN. Cerebellar hemorrhage after spinal surgery: case report and review of the literature. Eur Spine J. Jan 2006;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. St Louis EK, Wijdicks EF, Li H. Predicting neurologic deterioration in patients with cerebellar hematomas. Neurology. Nov 1998;51(5):1364-9. [Medline].

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

  6. Chalela JA, Monroe T, Kelley M, Auler M, Bryant T, Vandergrift A, et al. Cerebellar hemorrhage caused by remote neurological surgery. Neurocrit Care. 2006;5(1):30-4. [Medline].

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

  8. Arboix A, Bell Y, Garcia-Eroles L, et al. Clinical study of 35 patients with dysarthria-clumsy hand syndrome. J Neurol Neurosurg Psychiatry. Feb 2004;75(2):231-4. [Medline].

  9. Ausman JI. How I remove a spontaneous cerebellar hematoma in a deteriorating patient. Surg Neurol. Mar 2001;55(3):162. [Medline].

  10. Broderick J, Brott T, Tomsick T, et al. Management of intracerebral hemorrhage in a large metropolitan population. Neurosurgery. May 1994;34(5):882-7; discussion 887. [Medline].

  11. Chin D, Carney P. Acute cerebellar hemorrhage with brainstem compression in contrast with benign cerebellar hemorrhage. Surg Neurol. May 1983;19(5):406-9. [Medline].

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  13. Fisher CM, Picard EH, Polak A, et al. Acute hypertensive cerebellar hemorrhage: diagnosis and surgical treatment. J Nerv Ment Dis. Jan 1965;140:38-57. [Medline].

  14. Huff JS. Dr. C. Miller Fisher's description of acute cerebellar hemorrhage. J Emerg Med. Jul-Aug 1994;12(4):521-4. [Medline].

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  17. Pollak L, Rabey JM, Gur R, Schiffer J. Indication to surgical management of cerebellar hemorrhage. Clin Neurol Neurosurg. Jun 1998;100(2):99-103. [Medline].

  18. Rosen RS, Armbrustmacher V, Sampson BA. Spontaneous cerebellar hemorrhage in children. J Forensic Sci. Jan 2003;48(1):177-9. [Medline].

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

  20. Schievink WI, Maya MM. Quadriplegia and cerebellar hemorrhage in spontaneous intracranial hypotension. Neurology. Jun 13 2006;66(11):1777-8. [Medline].

  21. Taneda M, Hayakawa T, Mogami H. Primary cerebellar hemorrhage. Quadrigeminal cistern obliteration on CT scans as a predictor of outcome. J Neurosurg. Oct 1987;67(4):545-52. [Medline].

  22. Wijdicks EFM. Cerebellum and brain stem hemorrhages. In: The Clinical Practice of Critical Care Neurology. Lippincott-Raven; 1997:173-182.

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Further Reading

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Keywords

CH, cerebellar bleeding, intracerebellar hemorrhage, stroke of the cerebellum, stroke, computed tomography, head CT, cranial CT

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Contributor Information and Disclosures

Author

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Draga Jichici, BSc, MD, FRCP, Associate Clinical Professor, Department of Medicine, Division of Neurology and Critical Care Medicine, McMaster University, Canada
Disclosure: Biogen Honoraria Review panel membership; Sanofi Honoraria Speaking and teaching; Merk and Frost Honoraria Speaking and teaching; Teva Neurosciences Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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 Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Boehringer Ingelheim Honoraria Speaking and teaching; BMS/Sanofi Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Novartis Consulting fee Review panel membership

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health and Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Boston Scientific Honoraria Speaking and teaching; Concentric Medical None Review panel membership; Northstar Neuroscience  Review panel membership; ev3 Consulting fee Review panel membership

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