BackgroundGuidelines regarding recommendations for surgical treatment of spontaneous cerebellar intracerebral haemorrhage (ICH) differ. We aimed to systematically review the literature to assess treatment strategies and outcomes.MethodsWe searched PubMed and Embase between 1970 and 2019 for randomised or otherwise controlled studies and observational cohort studies. We included studies according to predefined selection criteria and assessed their quality according to the Newcastle-Ottawa Scale (NOS) and risk of bias according to a predefined scale. We assessed case fatality and functional outcome in patients treated conservatively or with haematoma evacuation. Favourable functional outcome was defined as a modified Rankin Scale score of 0–2 or a Glasgow Outcome Scale score of 4–5.ResultsWe included 41 observational cohort studies describing 2062 patients (40% female) with spontaneous cerebellar ICH. A total of 1171 patients (57%) underwent haematoma evacuation. Ten studies described a cohort of surgically treated patients (n=533) and 31 cohorts with both surgically and conservatively treated patients (n=638 and n=891, respectively). There were no randomised clinical trials nor studies comparing outcome between the groups after adjustment for differences in baseline characteristics. The median NOS score (IQR) was 5 (4–6) out of 8 points and the bias score was 2 (1–3) out of 8, indicative of high risk of bias. Case fatality at discharge was 21% (95% CI 17% to 25%) after conservative treatment and 24% (95% CI 19% to 29%) after haematoma evacuation. At ≥6 months after conservative treatment, case fatality was 30% (95% CI 25% to 30%) and favourable functional outcome was 45% (95% CI 40% to 50%) and after haematoma evacuation, case fatality was 34% (95% CI 30% to 38%) and 42% (95% CI 37% to 47%).ConclusionsControlled studies on the effect of neurosurgical treatment in patients with spontaneous cerebellar ICH are lacking, and the risk of bias in published series is high. Due to substantial differences in patient characteristics between conservatively and surgically treated patients, and high variability in treatment indications, a meaningful comparison in outcomes could not be made. There is no good published evidence to support treatment recommendations and controlled, preferably randomised studies are warranted in order to formulate evidence-based treatment guidelines for patients with cerebellar ICH.

Background and Purpose: The computed tomography angiography spot sign is associated with hematoma expansion, case fatality, and poor functional outcome in spontaneous supratentorial intracerebral hemorrhage (ICH). However, no data are available on the spot sign in spontaneous cerebellar ICH. Methods: We investigated consecutive patients with spontaneous cerebellar ICH at 3 academic hospitals between 2002 and 2017. We determined patient characteristics, hematoma expansion (>33% or 6 mL), rate of expansion, discharge and 90-day case fatality, and functional outcome. Poor functional outcome was defined as a modified Rankin Scale score of 4 to 6. Associations were tested using univariable and multivariable logistic regression. Results: Three hundred fifty-eight patients presented with cerebellar ICH, of whom 181 (51%) underwent a computed tomography angiography. Of these 181 patients, 121 (67%) were treated conservatively of which 15 (12%) had a spot sign. Patients with a spot sign treated conservatively presented with larger hematoma volumes (median [interquartile range]: 26 [7–41] versus 6 [2–13], P =0.001) and higher speed of expansion (median [interquartile range]: 15 [24–3] mL/h versus 1 [5–0] mL/h, P =0.034). In multivariable analysis, presence of the spot sign was independently associated with death at 90 days (odds ratio, 7.6 [95% CI, 1.6–88], P =0.037). With respect to surgically treated patients (n=60, [33%]), 14 (23%) patients who underwent hematoma evacuation had a spot sign. In these 60 patients, patients with a spot sign were older (73.5 [9.2] versus 66.6 [15.4], P =0.047) and more likely to be female (71% versus 37%, P =0.033). In a multivariable analysis, the spot sign was independently associated with death at 90 days (odds ratio, 2.1 [95% CI, 1.1–4.3], P =0.033). Conclusions: In patients with spontaneous cerebellar ICH treated conservatively, the spot sign is associated with speed of hematoma expansion, case fatality, and poor functional outcome. In surgically treated patients, the spot sign is associated with 90-day case fatality.

Background In patients with spontaneous cerebellar intracerebral hemorrhage (ICH) guidelines advocate evacuation when the hematoma diameter is > 3 cm. We studied outcome in patients with cerebellar ICH > 3 cm who did not undergo immediate hematoma evacuation. Methods We included consecutive patients with cerebellar ICH > 3 cm at two academic hospitals between 2008 and 2017. Patients who died < 24 h (h) were excluded because of probable confounding by indication. We determined patient characteristics, hematoma volumes, EVD placement, secondary hematoma evacuation, in-hospital and 3-month case-fatality, and functional outcome. Results Of 130 patients with cerebellar ICH, 98 (77%) had a hematoma > 3 cm of whom 22 (23%) died < 24 h and 28 (29%) underwent hematoma evacuation < 24 h. Thus, 48 patients were initially treated conservatively (mean age 70 ± 13, 24 (50%) female). Of these 48 patients, 7 (15%) underwent secondary hematoma evacuation > 24 h, of whom 1 (14%) had received an EVD < 24 h. Five others also received an EVD < 24 h without subsequent hematoma evacuation. Of the 41 patients without secondary hematoma evacuation, 11 (28%) died and 20 (51%) had a favorable outcome (mRS of 0–3) at 3 months. The 7 patients who underwent secondary hematoma evacuation had a decrease in GCS score of at least two points prior to surgery; two (29%) had deceased at 3 months; and 5 (71%) had a good functional outcome (mRS 0–3). Conclusions While cerebellar ICH > 3 cm is often considered an indication for immediate hematoma evacuation, there may be a subgroup of patients in whom surgery can be safely deferred. Further data are needed to assess the optimal timing and indications of surgical treatment in these patients.

Background: The CT angiography (CTA) spot sign is associated with hematoma expansion, mortality and poor functional outcome in supratentorial and pontine spontaneous intracerebral hemorrhage (ICH). However, no studies are available on the spot sign in patients with spontaneous cerebellar ICH. We therefore aim to assess its association with hematoma expansion and outcome in cerebellar ICH. Methods: We investigated consecutive patients with spontaneous cerebellar ICH treated non-surgically at three academic hospitals between 2002 and 2017. We determined patient characteristics, presence of the CTA spot sign, baseline hematoma volumes, hematoma expansion (>33% or >6ml), speed of expansion (baseline hematoma volume/time onset-CT scan) and in-hospital and 90-day mortality and functional outcome. Associations were tested using uni- and multivariable logistic regression. Results: We included 358 patients with cerebellar ICH of which 181 (51%) underwent a CTA. Of these 181 patients, 60 (33%) were treated surgically and therefore excluded from this study. This resulted in 121 patients of which 15 (12%) had a CTA spot sign. In univariable analyses, patients with a CTA spot sign presented with larger hematoma volumes [median (IQR): 22 (7-41) vs. 6 (3-14), p=0.005], higher rates of hematoma expansion [50% vs. 24%, p=0.167] and higher speed of expansion [median (IQR): 9 (21-2) vs. 2 (5-0), p=0.015]. Patients also had higher mortality at discharge [80% vs. 18%, p=<.001] and 90-days [80% vs. 26%, p=<0.001] and higher rates of poor functional outcome (mRS 4-6) at discharge [93% vs. 63%, p=0.020] and 90-days [93% vs. 53%, p=0.006]. In multivariable analyses correcting for age, sex and speed of expansion, the presence of the CTA spot sign is independently associated with 90-days mortality [OR 3.9, 95%CI 1.5-12.9] and 90-days poor functional outcome [OR 4.1, 95%CI 1.2-21.0]. Conclusions: In patients with spontaneous cerebellar ICH, the CTA spot sign is associated with hematoma expansion, speed of hematoma expansion, mortality, and poor functional outcome. This may assist physicians in the risk stratification of patients with spontaneous cerebellar ICH.