Cerebellar haematoma

Posterior fossa is a shallow space accommodating brainstem and cerebellum. Bleed in the cerebellum can cost life as it leads to rapid deterioration by hydrocephalus and upward herniation.

1. SURESH BISHOKARMA, MS MCH RESIDENT, NEUROSURGERY NINAS CEREBELLAR HAEMATOMA

2. Cerebellum is 140cm3.

3. Volumes of the Posterior Cranial Fossa, Cerebellum Vurdem ÜE, Acer N, Ertekin T, Savranlar A, İnci MF. Analysis of the Volumes of the Posterior Cranial Fossa, Cerebellum, and Herniated Tonsils Using the Stereological Methods in Patients with Chiari Type I Malformation.  The Scientific World Journal . 2012;2012:616934

4. ARTERIAL SUPPLY OF CEREBELLUM

5. LIFE THREATENING CONDITION CEREBELLAR BLEED

6. 10–15 % of all ICH High mortality: 48 hours

7. Hypertension: 60-80% AVM and Cavernoma Anticoagulants and blood dyscrasis Trauma Neoplasm Aneurysm Amyloid: rare Remote cerebellar hemorrhage Aetiology

8. In hypertensive patients : Rupture of cerebellar microaneurysms . Pathophysiology Charcot and Bouchard

9. Blood flow current

10. Early Vomiting , headache, ataxia Clinical feature

11. Hydrocephalus Confused , agitate or drowsy. VI nerve palsy: Dorsal portion of brainstem. Intermediate stage

12. Ipsilateral gaze paresis: Horizontal gaze centres . Facial paresis: Facial colliculus Horner’s syndrome: Sympathetic pathway running from the hypothalamus through the dorsal brain stem . Hemiparesis: Pyramid Stupur  coma and decerebrate Pinpoint pupil ®:Descending sympathetic pathways from hypothalamus to cervical cord is affected. Parasympathetic control of pupil in midbrain is preserved Medullary involvement : Cardiovascualar instability and ataxic respiration or apnoea . Late

13. Hydrocephalus , Direct brainstem compression by the hematoma and surrounding swelling, or both. Depressed GCS :

14. Brainstem compression Upwards herniation through the tentorial incisura or Downward tonsillar herniation through the foramen magnum. Death

15. WORK UP

16. Critical care: BP control and respiratory support Investigation Imaging Management include

17. CT scan head CTA MRI with MRA DSA IMAGING Location of hemorrhage ( vermian , hemispheric or both) Size of hemorrhage IVE Invasion into brain stem Presence of hydrocephalus Sign of brain stem impairment Presence and extent of perilesional edema Evidence of tight posterior fossa (TPF): Weisberg

18. EVIDENCE OF TIGHT POSTERIOR FOSSA ( TPF) WEISBERG 1986 14 patients WEISBERG 1986;14 PATIENTS

19. TREATMENT

20. GCS Cerebellar atrophy Size and Volume of hematoma Hydrocephalus D egree of basal cisternal compression Brain stem sign L ocation of the hematoma Anatomy of posterior fossa DECISION

21. Controversial Surgical evacuation of the hematoma External ventricular drainage Conservative treatment.

22. Outcomes after nonsurgical management were variable, with mortality rates between 9 and 75%.

23. Posterior fossa craniectomy and evacuation of the hematoma are not without risks. Postoperative recurrent hemorrhage can be fatal

24. In one series, the presence of hydrocephalus invariably resulted from brainstem compression and it was suggested that the presence of hydrocephalus necessitated a posterior fossa craniectomy and evacuation of the hematoma. Mathew P, Teasdale G, Bannan A, Oluoch-Olunya D: Neurosurgical management of cerebellar haematoma and infarct. J Neurol Neurosurg Psychiatry 59:287–292, 1995.

25. Ventricular drainage alone was observed to be ineffective in some cases. Outcomes after nonsurgical management were variable, with mortality rates between 9 and 75%. affirmed

26. When surgery is indicated controversy exists regarding whether ventricular drainage only, evacuation of the hematoma, or both procedures should be performed. Some surgeons recommend drainage of hydrocephalus as the only or initial procedure in all cases. Others recommend evacuation of the hematoma whenever surgery is indicated. Current management

27. Size and volume Cisterns Hydrocephalus Brain stem size Consciousness Surgical evacuation: Indication

28. GCS 14 or 15 and < 3 cm : Conservatively GCS scores of 13 or less and ≥ 3 cm: surgery Clot size between 2-3cms, if level of consciousness has altered, should be considered. Size of hematoma Kobayashi et al; 52 patients

29. 3 to 4 cm or a volume of more than 15 ml : Surgical evacuation of the hematoma. Kobayashi et. Al. Treatment of hypertensive cerebellar hemorrhage: Surgical or conservative management? Neurosurgery 34:246–251, 1994 .

30. Size threshold – 3 cm vs. 4 cm Radiographic evidence of brainstem compression Accounts for edema Clinical examination

31. Patient with hematoma size of >70cm3 did not respond to any treatment and died within 48hrs.

32. Timing of Surgical Intervention “Prophylactic ” vs. at time of deterioration ISSUES TO CONSIDER

33. Q uadrigeminal cistern into 3 groups: Grade I (normal), Grade II (compressed), Grade III (absent). Good outcomes: Grade I: 88 %, Grade II: 69 %, Grade III : 0 % CISTERNS Taneda et al.  75 Patients

34. The appearance of the fourth ventricle was divided into 3 groups: Grade I (normal size and configuration), Grade II (partially compressed and shifted) Grade III (completely obliterated). 4 th ventricle Kirollos et al. 50 patients

35. Studied in 25 patients with cerebellar bleed. Stable Grade I and II: Conservatively . Grade I or II compression : only ventricular drainage 15 (60%) Grade I or II compression did not require clot evacuation. Acute deterioration to comatose state occurred in 6 (43%) of the 14 patients with Grade III compression who were conscious at presentation; none of them experienced good outcomes. Kirollos et al

36. BEST Glasgow coma scale score of 14 or greater Small hemorrhage (< 30 mm ) Without hydrocephalus Without basal cistern effacement CRITERIA FOR MEDICAL CONSERVATIVE TREATMENT WORST Comatose Flaccid Without brainstem reflexes Large midline hemorrhage

37. Stereotactic aspiration, Endoscopic bur hole evacuation, Local infusion of a thrombolytic agent : TPA Other modalities

38. Low GCS at admission Obliteration of 4 th ventricle and peri-mesenchephalic cistern. Hydrocephalus T2W MRI: high signal intensity in brain stem PROGNOSIS

39. MANAGEMENT ALGORITHM Kirollos RW et al. Management of spontaneous cerebellar hematomas: a prospective treatment protocol. Neurosurgery.2001;49(6 ): 1378-86. CSF-D: EVD or VPshunt .

40. CEREBELLAR HAEMATOMA NINAS