TREATMENT OF SPONTANEOUS INTRACEREBRAL AND INTRACEREBELLAR HEMORRHAGES

Most primary intracerebral and intracerebellar hemorrhages are hyperte nsive, and the most common site is the basal ganglion. In typical basa l ganglia hematoma, surgery offers no benefit, and such patients shoul d be treated conservatively. Surgery is not indicated in pontine hemat omas either. Cerebellar hematomas may block the circulation of the cer ebrospinal fluid and cause an acute life-threatening hydrocephalus; th erefore such hematomas should be operated on. Subcortical hematomas, w hich are usually not associated with hypertension and may be due to tu mor or vascular malformation, should as a rule be operated on. Carotid angiography is necessary for most supratentorial hematomas to exclude the presence of aneurysm or arteriovenous malformation. Secondary hem atomas from ruptured arterial aneurysm should be operated on as urgent ly as traumatic intracranial hematomas if the patient's level of consc iousness is deteriorating and if there is severe neurological deficit. Hematomas due to arteriovenous malformation must sometimes be evacuat ed as an emergency measure if the patient is unconscious, and the malf ormation should be excised if technically possible. The operation shou ld preferably be postponed to the second week after the bleeding if th e patient's level of consciousness is, not deteriorating, since the ma lformation is more easily excised after the brain edema has subsided. Hematomas associated with anticoagulant treatment should be evacuated if the hematoma is expansive and if the patient is unconscious or somn olent but the results are not very good. Hematomas of hemophiliacs sho uld be evacuated, and these patients need an appropriate replacement t herapy.