Cerebellar Hemorrhage Treatment & Management

Updated: Dec 05, 2016
  • Author: Sonal Mehta, MD; Chief Editor: Helmi L Lutsep, MD  more...
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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. There has been a call for large prospective randomized controlled trials to determine best treatment. [6]

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. In addition to neurologic deterioration, development of brainstem compression or hydrocephalus are indications for surgical treatment. [7]

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. For infratentorial hemorrhages, the GCS has been shown to be a predictor of outcome. [8]

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.

Hyperosmolar therapy with mannitol or hypertonic saline may be considered preoperatively in patients with a tight posterior fossa, although not much data exist to support these agents.

Persistent hypertension (mean arterial pressure >130 mm Hg) may indicate judicious use of labetalol or another titratable antihypertensive agent, such as nicardipine.

In symptomatic bradycardia reflecting Cushing response, atropine (0.5-1 mg) may be beneficial if hypotension is present.

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Surgical Care

Indications for surgery remain controversial. [9]

Ventriculostomy may be indicated in patients with hemorrhage and hydrocephalus but is controversial as well, and is not recommended as an alternative to surgical evacuation as it may in turn be harmful. [9, 7]

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, [10, 11] but a specific size recommendation is lacking in more recent recommendations. [9, 11]

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. [12]

  • 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. [13, 14, 15, 16]
  • Endoscopic hematoma evacuation has also been reported to have been effective in a small number of patients.
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Consultations

It is reasonable to 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 are strongly recommended.

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