39 Cerebellar Hemorrhage

Julius July and Eka Julianta Wahjoepramono

Fig. 39.1 Plain computed tomography scan showing left cerebellar hemorrhage (A) with e ffacement of 4th ventricle and (B) enlargement of the lateral ventricles.

Clinical Presentation

A 55-year-old man with a long history of poorly controlled hypertension, diabetes mellitus, and heavy smoking presents to the emergency room with acute decreased level of conscious.

This morning, he awakened with a headache that has progressively gotten worse.

On physical examination, he opens his eyes spontaneously and localizes the pain. There is no obvious weakness in his extremities. Pupils are both 3 mm and responsive to light. Initial blood pressure is 200/110 mm Hg.

A computed tomography (CT) scan is obtained and shown in Fig. 39.1.

Questions

What is your initial management?
Describe your surgical plan.
After you open the dura, you observe a very swollen and tight brain. What are your steps in managing intra-operative brain swelling?
Describe your postoperative care.

Answers

What is your initial management?

The cerebellar hemorrhage seen on CT is most likely due to hypertension.

A small number of patients can present with microaneurysm of the posterior circulation, which rupture and give a similar clinical picture.1

The frequency of cerebellar hemorrhage ranges between 5–10% of all intracranial hemorrhages (ICHs), and occurs predominantly in the older age groups, from the sixth to the eighth decades.

The history of diabetes in this case is also considered a general risk factor for developing a cerebellar hemorrhage.

Recommendation for surgical intervention on cerebellar hemorrhage include

Patients with Glasgow Coma Score (GCS) ≤13 or with hematoma size ≥4 cm.

Ventricular catheter placement is recommended for patients with hydrocephalus and no coagulopathy. Most cases with hydrocephalus also require evacuation of the hematoma.

The presence of the “tight posterior fossa” (TPF) concept, described by Weisberg et al.,² warrants surgical intervention. Weisberg defines this concept as

Obliteration of the basal cistern of the posterior cranial fossa

Enlargement of the third ventricle, lateral ventricle, and temporal horn

Effacement of the 4th ventricle

The TPF does not only depend on the size of the hematoma. A hematoma of similar size may exert widely differing amounts of compression. This is probably due to several factors including patient’s age, the amount of cerebellar atrophy and the anatomy of the posterior fossa. Based on the TPF concept, the critical size for hematoma evacuation can be reduced by 5–10 mm to a size of 3 cm.^1,2

Intensive therapy is not indicated in patients with absent brainstem reflexes and flaccid quadriplegia, that is, in moribund condition.^1–3
Describe your surgical plan.
- Initially, a ventricular catheter is inserted (one may choose the entry site at Kocher’s point or a Frazier burr hole site). Two to 3 cc of cerebrospinal fluid (CSF) are drained slowly to control the intracranial pressure (ICP) then the drainage is stopped to avoid upward herniation.
- A suboccipital craniectomy is then performed with goal of removing the ICH, decompressing the brainstem, and relieving hydrocephalus. The external drain can be opened after the dural opening.
- A transverse incision along the folia closest to the most superficial part of the clot is performed. After removing the ICH, meticulous hemostasis should be completed. The blood clot should be sent to histopathology for examination.
- Very often the cerebellum itself will swell after the surgery. It is better to close the dura via a duraplasty, using pericranium, fascia lata, or synthetic dura.
- The ventricular catheter in general is kept temporarily. However, some cases necessitate conversion to a permanent ventriculoperitoneal shunt.^1,3
After you open the dura, you observe a very swollen and tight brain. What are your steps in managing intraoperative brain swelling?
- The following is a checklist of steps to ensure proper management of intraoperative posterior fossa swelling^4,5:
  - Elevate the patient’s head to above 30 degrees.
  - Check neck positioning for obstruction of venous return and readjust as necessary.
  - Hyperventilate to a PCO₂ of 30–35 mm Hg.
  - Infuse a dose of mannitol and/or Lasix (Aventis Pharmaceuticals, Parsippany, NJ).
  - Ensure adequate sedation and pharmacologic muscle paralysis.
  - Decompress the hematoma!
  - Drain some CSF from the ventriculostomy.
  - Open the cisterna magna and drain some more CSF.
  - One may need to resect parts of the cerebellar hemisphere.
  - Ensure that the foramen magnum is open.
  - If the swelling is still uncontrollable, then consider the following causes:
    - Intraparenchymal hematoma in a different location
    - Contralateral or supratentorial subdural or epidural hematoma
    - Cytotoxic edema from trauma
    - Venous infarction
  - In intractable cases, some of the following steps may be considered:
    - Duraplasty and quick closure
    - Keeping the bone flap out (i.e., craniectomy)
    - Obtaining an emergent CT scan of the head and considering going back to the operating room for further exploration.
    - In the past, exploratory supratentorial burr holes were suggested. However, with the advent of fast spiral CT scanners, an adequate scan can be completed within minutes eliminating the need and potential risks associated with such a procedure.
Describe your postoperative care.
- A postoperative CT scan should be completed within 24 hours (Fig. 39.2).
- As the patient’s neurologic condition improves, he may be transferred to the neurosurgical ward and subsequently discharged from the hospital once the blood pressure remains under control with oral antihypertensives.^1,3