|Year : 2013 | Volume
| Issue : 4 | Page : 358-363
Cerebellar hematomas: management dilemmas
Ehab Ezzat El Gamal, Ashraf Mohamed Farid
Department of Neurosurgical, Faculty of Medicine, Tanta University, Tanta, Egypt
|Date of Submission||05-Jul-2013|
|Date of Acceptance||09-Sep-2013|
|Date of Web Publication||1-Feb-2014|
Ashraf Mohamed Farid
Neurosurgical Department, Tanta Faculty of Medicine, Tanta
The aim of the study was to evaluate and investigate the best guidelines for conservative and surgical management of cerebellar hematomas of different etiologies.
Patients and methods
A prospective and retrospective study was conducted on 36 consecutive patients (20 male and 16 female) admitted to the Tanta Neurosurgical Department during the period from July 2007 to December 2012. We followed the fourth ventricular grading scale, hematoma size, and the Glasgow coma score in our decision-making on the basis of the clinical and neuroimaging studies. Surgical evacuation was performed on 20 of 36 patients. Cerebrospinal fluid diversion was performed on 10 patients (intraoperative external ventricular drainage, ventriculoperitoneal (VP) shunt, Endoscopic third Ventriculostomy (ETV)) either alone or as adjunctive to the surgical evacuation. Sixteen patients did not undergo surgical evacuation. Glasgow coma score was 12 or greater in 20 patients, 8-11 in 11 patients, and 7 or less in five patients.
The degree of fourth ` ventricular compression was grade I in six patients, grade II in 19, and grade III in 11. Hydrocephalic changes were evident in 19 patients. Intraventricular hemorrhage was detected in computed tomography scans of 16 patients. Thirty-three patients had a history of hypertension, whereas the other three were suffering from bleeding tendencies due to hepatic diseases. Twenty-six patients had good outcome, whereas 10 died due to either recurrence after evacuation because of uncontrollable blood pressure or associated supratentorial hemorrhages or GCS of less than 7 on admission.
The surgical management of intracerebellar hematomas is still the main strategy; hence, we should correlate the hematoma size, fourth ventricular grade, medical condition of the patient, and initial clinical presentation in the decision-making.
Keywords: Cerebellar hemorrhage, Glasgow coma scale, hydrocephalus, intraventricular hemorrhage, outcome
|How to cite this article:|
El Gamal EE, Farid AM. Cerebellar hematomas: management dilemmas. Tanta Med J 2013;41:358-63
| Introduction|| |
Spontaneous cerebellar hemorrhage is defined as bleeding into cerebellar parenchyma without accompanying trauma and constitutes only 5-10% of all intracerebral hemorrhages. It could result from an arterial or venous rupture in the area of the dentate nucleus. Cerebellar hemorrhage is most commonly caused by hypertension. Further etiologies include vascular malformations, aneurysms, inherited or acquired coagulopathy, and tumor bleeding , .
Spontaneous cerebellar hematomas represent 5-13% of all cases of spontaneous intracranial hemorrhage. These hematomas are associated with high mortality rates of 20-75%, irrespective of the mode of treatment, with higher values being reported for the pre-computed tomography (pre-CT) era. Current overall surgical mortality rates remain up to 20-50%. Management of grave cases as well as treatment of patients in good neurological condition could be straightforward; however, the group of patients between these two extremes poses a dilemma in decision-making during treatment. The depressed level of consciousness in patients with cerebellar hematomas could be attributable to hydrocephalus, direct brainstem compression by the hematoma and surrounding swelling, or both. Decision-making is required for selection of the appropriate treatment option , .
Kobayashi et al.  have proposed their criteria for surgical therapy, generally agreeing that a small hematoma could be treated conservatively, whereas a large one requires surgical treatment. The surgical indication for medium-size hematomas remains controversial. Most of the reports dealing with indications for surgery are on the basis of the retrospective analysis of clinical data, such as CT scan findings, brainstem reflexes, and consciousness level.
| Patients and methods|| |
A prospective and retrospective study was conducted on 36 consecutive patients (20 male and 16 female) admitted to the Tanta Neurosurgical Department during the period from July 2007 to December 2012. Patients with any suspected vascular lesion or hemorrhagic neoplasms were excluded from our study.
In our decision-making on the basis of the clinical and neuroimaging studies, we tried to correlate the two protocols. The first depends on the fourth ventricular grading, designed by Kirollos et al.  , where grade I represents normal size and configuration, located in the midline [if intraventricular hemorrhage (IVH) is present, cerebrospinal fluid (CSF) is still visible in the fourth ventricle]; grade II represents partially compressed, distorted or shifted to the contralateral side; and grade III represents complete obliteration, with anterior shift distorting the brainstem and obliterating the prepontine space (even if the fourth ventricle is partially compressed). The second depends on the hematoma size and the Glasgow coma score (GCS), designed by Bullock et al.  . Patients with mass effect on CT scan (defined as distortion, dislocation, or obliteration of the fourth ventricle; compression or loss of visualization of the basal cisterns; or the presence of obstructive hydrocephalus; or with neurological dysfunction or deterioration attributable to the lesion) underwent operative intervention. Patients with lesions and no significant mass effect on CT scan and in the absence of signs of neurological dysfunction were managed by close observation and serial imaging. Routine laboratory investigations were mandatory to detect coagulopathies and other medical risks such as diabetes or renal disease. Surgical evacuation was performed on 20 of 36 patients. Intravenous nitroglycerine was the antihypertensive medication chosen by the anesthesiologist, together with the intravenous anesthesia. CSF diversion was performed alone on 10 patients [intraoperative external ventricular drainage (EVD), VP shunt, and ETV] (in three patients where the first patient was grade I and massive hydrocephalus (HCP), the second patient was grade III with GCS 4, and the third patient was medically unstable and had a high anesthetic risk; ETV was performed for the patient as an alternative procedure where the intact CSF pathways were emphasized) or as adjunctive to the surgical evacuation to decrease ntracranial pressure (ICP) in seven patients with marked hydrocephalus (HCP). Sixteen patients did not undergo surgical evacuation. ICU management was planned for all patients irrespective of the treatment modality and routine laboratory investigations.
| Results|| |
The age ranged between 42 and 95 years. This study included 16 female patients and 20 male patients. Nineteen of the 36 patients were older than 60 years. In our study, 35 of 36 patients were hypertensive and three were associated with cardiac and hepatic diseases. Fourth ventricular grade I was found in six patients, grade II was found in 19 patients, and grade III was found in 11 patients. Variable hydrocephalic changes were present in 19 patients, whereas normal sized ventricles were noticed in CTs of 17 patients. Sixteen CT scans revealed intraventricular hemorrhage (IVH), whereas 20 scans did not. GCS was 12 or more in 20 patients, 8-11 in 11 patients, and 7 or less in five patients. Hypertension was the main medical risk factor; only three of our patients had bleeding tendency due to hepatic disease. Good outcome was achieved in 26 patients (72%), whereas mortality was observed in 10 patients (28%). Eight of the dead patients had IVH. Nine of the dead patients had hydrocephalic changes. Five of the 10 dead patients had GCS of 4-8. Three of the dead patients died because of postoperative recurrence. Sixteen of the patients with good outcome were subjected to clot evacuation. Seven of the patients with good outcome were subjected to CSF diversion procedure. Outcome was, thus, dependent on the initial presentation and associated medical conditions [Figure 1] and [Figure 2].
| Discussion|| |
In our study, we couldn't rely on single criterion whether the fourth ventricular grading or hematoma size and mass effect. Kirollos et al.  reported that when surgery is indicated, controversy exists with respect to performing ventricular drainage only, evacuation of the hematoma, or both procedures. Some surgeons recommend drainage of hydrocephalus as the only or initial procedure in all patients. Others recommend evacuation of the hematoma whenever surgery is indicated. Posterior fossa craniectomy and evacuation of the hematoma are not without risks. Postoperative recurrent hemorrhage could be fatal (three of our patients died because of recurrence). In their series, the rate of postoperative death resulting from general causes was increased among patients with pre-existing suboptimal general conditions and among patients in the older age group, when patients were subjected to surgery and anesthesia. Death might also occur among patients treated conservatively. In our study, the CSF diversion was effective in our patients. In general, Kirollos et al.  reported that ventricular drainage alone was observed to be ineffective in some patients. The outcome after nonsurgical management was variable, with mortality rates ranging between 9 and 75% (10 of the 36 patients, 28%, in our study). Surgery was not attempted for patients considered to be at high risk in many series, whereas primarily patients in good neurological condition were included in other series.
However, D'Avella et al.  described clinicoradiological findings and prognostic factors; a general consensus emerged from this analysis that a conservative approach could be considered a viable and safe treatment option for noncomatose patients with intracerebellar clots measuring 3 cm or less, except when associated with other extradural or subdural posterior fossa focal lesions. In addition, a general consensus was reached that surgery should be recommended in all patients with clots larger than 3 cm. The pathogenesis, biomechanics, and optimal management criteria of these rare lesions are still unclear, and larger observational studies are necessary. Yanaka et al.  reported that MRI clearly demonstrated brainstem damage, and high signal intensity in the brainstem was a significant prognostic factor for determining outcomes in patients with spontaneous cerebellar hemorrhage, who were in poor-grade condition. We did not rely upon this neuroimaging modality in our study. CT was the main modality.
Kobayashi et al.  described new criteria on the basis of the patient's GCS at admission and the maximum diameter of hematoma as disclosed by CT. The criteria are as follows: (i) patients with GCS of 14 or 15 and with a hematoma of less than 40 mm maximum diameter are treated conservatively; (ii) for patients with GCS of 13 or less at admission or with a hematoma measuring 40 mm or more, hematoma evacuation with decompressive suboccipital craniectomy should be the treatment of choice; and (iii) for patients whose brainstem 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 recent patients. This protocol was very important in our decision-making also.
In our study, the antihypertensive used was nitroglycerine. Qureshi et al.  emphasized that intravenous nicardipine initiated within 3 h following the onset of ICH and continued for the next 24 h reduced the likelihood of death and disability at 3 months after intracerebral hemorrhage (ICH).
Waidhauser et al.  concluded that all patients with an early disturbance of consciousness due to cerebellar hemorrhage with brainstem compression and with CT signs of upward transtentorial herniation should undergo immediate surgery of the posterior fossa. In these patients, ventricular drainage alone led to fatal results. Immediate surgical decompression of the posterior fossa was life-saving in patients with brainstem compression and upward transtentorial herniation. Mortality was 57% in comatose patients and 9% in drowsy or stuporous patients. Ventriculostomy alone was the treatment of choice in patients with only hydrocephalus in the absence of brainstem compression or transtentorial herniation.
In our study, we had only three patients with bleeding diathesis due to hepatic disease. All were managed nonsurgically, and coagulopathy was corrected; two of them were also cardiac. Their ages were 53, 60, and 85 years. The fourth ventricular grading scale was 2 in the 85-year patient and 3 in the other two. All of them died because of medical risks. Dejan et al.  with respect to the problem of coagulopathy, reported that the presentation of intracranial hemorrhage with an isolated prolonged activated partial thromboplastine time (aPTT) is concerning for an acquired hemophilia with factor VIII deficiency. Other causes of isolated prolonged aPTT, such as a lupus anticoagulant, must also be considered. Preoperative identification and workup of the coagulation abnormality is essential to guide initial treatment.
In our study, ETV was performed in one patient as an alternative procedure where the intact CSF pathways were emphasized. Roux et al.  concluded that the best results in third ventriculocisternostomy had been obtained in patients with previously intact CSF pathways that have been interrupted by a lesional process. Third ventriculocisternostomy could be considered as a treatment option in selected patients suffering from hydrocephalus associated with posterior fossa hematomas. A larger prospective study is needed to confirm the value of third ventriculocisternostomy versus EVD in that situation. The initial careful selection of patients who could benefit from the procedure appears essential to ensure the success of third ventriculocisternostomy under these conditions.
Yacubian et al.  , Celikoglu et al.  , Marquardt et al.  , König et al.  , Vogels et al.  , Karaeminogullari et al.  , Varnavas et al.  , and Friedman et al.  reported that remote cerebellar hemorrhage (RCH) could most commonly follow supratentorial neurosurgical procedures, performed with the patient in the supine position, that involve opening of CSF cisterns or the ventricular system (such as unruptured aneurysm repair or temporal lobectomy). Preoperative aspirin use and moderately elevated intraoperative systolic blood pressure are potentially modifiable risk factors associated with the development of RCH. Although RCH can cause death or major morbidity, most patients are asymptomatic or exhibit a benign course. Cerebellar 'sag' as a result of CSF hypovolemia, causing transient occlusion of superior bridging veins within the posterior fossa and consequent hemorrhagic venous infarction, is the most likely pathophysiological cause of RCH. Chalela et al.  , Konya et al.  , and Reza et al.  proposed similar explanation. Hiroyuki et al.  and Mandonnet et al.  proposed a mechanism for the development of RCH, which is an increase in the transluminal venous pressure caused by intracranial hypotension from the CSF loss, resulting in the rupture of a blood vessel. Another theory is that the downward displacement of the cerebellum by intracranial hypotension causes stretching, and possibly tearing, of the superior vermian veins. They thus concluded that it is important to be aware of CSF leakage as a potential causative factor of RCH, with unexplained headache and neurological deterioration after spinal surgery. If a large CSF loss seems to be expected during or after spinal surgery, it is necessary to prevent CSF leakage by measures such as a water-tight repair of the dura, the use of subfascial drainage without negative pressure, and extended bed rest. CT should be performed as soon as possible, as the early diagnosis and treatment of this complication are of great importance to the patient outcome.
Young et al.  illustrated a case of cardiopulmonary complications of acute cerebral injury and proposed that supraventricular tachycardia could be an initial presenting symptom of cerebellar hemorrhage. They suggested considering the possibility of neurological insult in patients without apparent cardiac risk but presenting with a fulminant picture of cardiac arrhythmia, pulmonary edema, or myocardial injury.
Only one patient, 60 years of age with GCS of 8 and fourth ventricular grading score of 3, had a history of using antiplatelet drugs. We tried to correct the prolonged bleeding time, but the patient died because of hematoma expansion. Despite the reported controversy about the relationship between the use of antiplatelet and hematoma expansion, Moussouttas et al.  concluded that patients reporting antiplatelet use experienced similar degrees of hematoma expansion compared with patients not reporting antiplatelet use. Paolini et al.  reported a 17-year-old boy, who developed a cerebellar hemorrhage after specific symptoms of upper respiratory tract infection. His past medical history and emerging evidence of systemic bleeding yielded a diagnosis of recurrent Henoch-Schönlein syndrome. This was the fourth time the disease had recurred since the age of 4 years. The patient underwent surgical treatment and returned to his normal activities.
In our study, we correlated between the fourth ventricular grading scale and the hematoma size in the CT scan before decision-making whether to conserve or to operate. Pozzati et al.  , also emphasized that cerebellar hematoma is generally regarded as a rapidly progressive condition that necessitates prompt evacuation in most cases. Unlike adults, where hypertension is the most common etiological factor, children generally have underlying structural lesions (angiomas, tumors) that per se demand surgical intervention. As several reports describe nonsurgical management of cerebellar hematomas in adults, the spontaneous resolution of juvenile cerebellar hematomas is almost unknown. They described a 16-year-old boy with a cerebellar hematoma of obscure etiology that was managed conservatively. This report indicated that nonsurgical treatment of cerebellar hematomas, once structural lesions have been excluded, might be attempted in neurologically stable children.
In our study, the age ranged between 42 and 95 years. We excluded cases that were secondary to a lesion. The outcome was dependent on the initial presentation and associated medical conditions. Chadduck et al.  reported that cerebellar hemorrhages in the pediatric age group are caused more often by arteriovenous malformations, tumors, and blood dyscrasias than in adults, whose hemorrhages are caused most often by hypertension. The outcomes of pediatric patients with cerebellar hemorrhages are potentially far better than those of adults; therefore, rapid use of neuroimaging facilities and surgical treatment is indicated for pediatric patients with cerebellar hemorrhages even if they have dilated and fixed pupils and other impaired brainstem reflexes at the time of their initial presentation. Neonates with cerebellar hemorrhages may not require surgical treatment.
Despite absence of patients with renal impairment in our study, we found it worthy to mention the experience of some authors to put in consideration when facing similar conditions. Caruso et al.  reported that intraparenchymal hematomas within the cranium are often associated with brain edema. A hemorrhagic intracranial mass in a patient with acute renal failure who requires renal replacement therapy may further increase the risk of developing cerebral edema and associated elevated ICP, if the case is managed using conventional hemodialysis. They reported a case of a patient who had a spontaneous cerebellar hemorrhage with associated obstructive hydrocephalus and acute oliguric renal failure. The patient's unstable condition prevented her from undergoing surgical hematoma evacuation. This patient was managed successfully with EVD and continuous venovenous hemodialysis. To our knowledge, this was the first report of the successful use of continuous venovenous hemodialysis in the treatment of a patient with a life-threatening intracranial hemorrhagic mass lesion.
In our study, we were confronted with five patients with GCS of 7 or less. One of them died. Nayil et al.  described cerebellar hematomas as an unfavorable site, especially if the patient presents with an early loss of consciousness. Patients with a good GCS could be managed conservatively, although there is a group of patients with few CT scan features who are likely to deteriorate. Patients with a poor clinical grade should be operated upon early without loss of time. Tight posterior fossa and fourth ventricular obliteration are predictors of a poor outcome. In our study, one patient from this group (≤7) improved from GCS of 7 to 15 after surgery, denoting to give patients their chance if possible.
This study included 16 female patients and 20 male patients. Age ranged from 42 to 95 years. Nineteen of the 36 patients were older than 60 years. As mentioned before, GCS of 7 or less was found in five patients. Salvati et al.  reported that eight of 50 patients, two men and six women, were older than 80 years. No significant differences were found between both sexes. Thirty patients (60%) were comatose on admission. At neurological examination, 26 patients (52%) had GCS between 9 and 11. On admission, four patients (8%) were in a deep coma (GCS of 3). The mean time elapsed between the onset of signs and symptoms of hemorrhage and admission to the hospital was 13 h (range 4-72 h). In most patients (80%), the first symptom was headache. Eighteen patients had diabetes mellitus (36%), 16 (32%) had arterial hypertension, seven (14%) had blood coagulation disorders, and eight (16%) had liver disease. Nineteen patients (38%) had two or more of these conditions (In our study, 35 of 36 patients were hypertensive, three were associated with cardiac and hepatic diseases). Sixteen patients (32%) involved the vermis, 30 patients (60%) involved the cerebellar hemisphere, and the remaining four patients (8%) involved both sites. Salvati et al.  concluded that in patients presenting with spontaneous cerebellar hemorrhage, the essential criteria indicating surgery are a hematoma measuring 40 mm 3 , 30 mm on CT imaging in the cerebellar hemisphere or 35 mm 3 , 25 mm on CT imaging in the vermis, the presence of a tight posterior fossa, and a GCS less than 13. Dammann et al.  and Andrews et al.  reported similar results.
A recent study by Farhat et al.  on the 30-day prognosis and risk factors in 352 patients treated for ICH confirmed once again that when compared with all other ICHs, cerebellar hematomas had the best outcome after the first month and brainstem and multilobar ICHs had the worst outcome. The dentate nuclei are the most common substrate. The hematoma extends into the hemispheric white matter and often into the fourth ventricle, where it causes either brainstem compression or direct invasion. Rarely, cerebellar hemorrhage involves only the vermis. Hypertension and anticoagulation are the two most important causative factors for cerebellar hemorrhage.
| Conclusion|| |
The surgical management of intracerebellar hematomas is the main strategy; we should correlate the hematoma size, fourth ventricular grade, medical condition of the patient, and initial clinical presentation in the decision-making.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]