Management of spontaneous cerebellar hematomas: A prospective treatment protocol

OBJECTIVE: To identify easily applicable guidelines for the surgical and co nservative management of spontaneous cerebellar hematomas. METHODS: A treatment protocol was developed and prospectively applied for t he management of 50 consecutive cases of cerebellar hematomas. The appearan ce of the fourth ventricle, adjacent to the hematoma, on computed tomograph ic scans was divided into three grades (normal, compressed, or completely e ffaced). The degree of fourth ventricular compression was correlated with t he size and volume of the hematoma and the presenting Glasgow Coma Scale (G CS) score. The hematoma was surgically evacuated for all patients with Grad e III compression and for patients with Grade II compression when the GCS s core deteriorated in the absence of untreated hydrocephalus. Patients with Grade I or II compression were initially treated with only ventricular drai nage in the presence of hydrocephalus and clinical deterioration. RESULTS: The degree of fourth ventricular compression was classified as Gra de I in 6 cases, Grade II in 26, and Grade III in 18. The degree of fourth ventricular compression was significantly correlated with the volume of the hematoma (r(s) = 0.67, P < 0.0001), hydrocephalus (r(s) = 0.44, P = 0.001) , the preoperative GCS score (r(s) = 0.43, P = 0.001), the maximal diameter of the hematoma (r(s) = 0.43, P = 0.001), and a midline location of the he matoma (chi (2) = 6.84, P < 0.009). Acute deterioration in GCS scores occur red for 6 (43%) of 14 patients with Grade III ventricular compression who w ere conscious at presentation. Thirteen patients with Grade I or II ventric ular compression and stable GCS scores of more than 13 were treated conserv atively. Nine patients were treated with ventricular drainage only, and 28 underwent posterior fossa craniectomy and evacuation of the hematoma with v entricular drainage. The mortality rate at 3 months was 40%. None of the pa tients with Grade III fourth ventricular compression and GCS scores of less than 8 at the time of treatment experienced good outcomes. Overall, 15 (60 %) of 25 patients with hematomas with maximal diameters of more than 3 cm a nd Grade I or II compression did not require clot evacuation. CONCLUSION: Conscious patients with Grade III fourth ventricular compressio n should undergo urgent clot evacuation before deterioration. Surgical evac uation of the clot may not be required for large hematomas (> 3 cm) if the fourth ventricle is not totally obliterated at the level of the clot.