Cerebellar Hemorrhage Treatment & Management

Updated: Apr 19, 2022
  • Author: Sonal Mehta, MD; Chief Editor: Helmi L Lutsep, MD  more...
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Treatment

Approach Considerations

Ideally, admit patients to the care of critical care physicians with expertise in managing intracranial hemorrhages.

Careful monitoring for level of consciousness, vital signs, and intracranial pressure (ICP) is needed for some patients.

The risk of sudden deterioration is high and mandates the attention that is available in an intensive care unit.

If immediate surgical intervention is deferred, a deteriorating clinical course may necessitate surgery at a later time.

  • Posterior fossa craniotomy and evacuation of the hemorrhage may be necessary for patients with worsening clinical condition.

  • If surgical therapy is prompt, some comatose patients still may have a good clinical outcome.

Physical and occupational therapy may be useful in patients who are in stable condition.

For facilities without neurosurgical care for hemorrhage management, transfer to a specialized center should occur after stabilization.

  • Transfer should occur only after discussion with an accepting physician.

  • Transfer personnel should be skilled in critical care management.

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Medical Care

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 > 140 mm Hg) may indicate judicious use of labetalol or another titratable antihypertensive agent, such as nicardipine or clevidipine. [11]

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

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. [12]

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. [13]

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. [5]

However, clear consensus does not exist regarding many patients who fall between these extremes. Variation in surgical treatment exists even within a geographic region.

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Surgical Care

Indications for surgery in cerebellar hemorrhage (CH) remain controversial. [14]

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. [14, 13]

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, [15, 16] but a specific size recommendation is lacking in more recent recommendations. [14, 16]

Patients with a large central clot and absent brainstem reflexes have a poor prognosis. In these cases, some advocate supportive therapy only.

Minimally Invasive Surgery (MIS) has shown some promise as an alternative to conventional surgical manuevers in small case series, but further studies are warranted. [17, 18, 19]

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. [20]

  • 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. [21, 22, 23, 24]

  • Endoscopic hematoma evacuation has also been reported to have been effective in a small number of patients.

A large meta-analysis comparing surgical and medical treatment for CHs did not find improved functional outcomes with surgical hematoma evaluation, and showed that patients with smaller hematomas may have worse outcomes with surgical treatment. This reflects a continuing need for better identification of variables that might affect outcomes with surgical care and appropriate patient selection for these therapies. [25]

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Consultations

Patients with acute cerebellar hemorrhage (CH) should be monitored closely in a critical care setting, with consulting neurologists available.

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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