Clinical and CT scan assessment of benign versus fatal spontaneous cerebellar haematomas

Abstract

We have studied 15 cases of spontaneous intracerebellar haematomas in 9 males and 6 females. A significant correlation between the clinical presentation and the CT scan features of benign and fatal haemorrhages of the cerebellum is presented. Diagnostic computerized tomographic studies were performed in a mean interval of 31 hours after the initial symptoms. 60% were diagnosed and treated in less than 24 hours; 11 patients had haematomas larger than 3 cm, and 5 (45%) of these cases died with evidence of irreversible brain-stem damage. Twelve (80%) showed compression of the fourth ventricle, 9 (60%) obliteration of the brain-stem cisterns and 8 (53%) ventricular dilatation. 8 cases were treated with surgery; 50% of them showed neurological improvement, including two cases with signs of brain-stem compression. 7 patients who were treated conservatively were followed closely with repeated CT scans, which showed that resolution of the mass effect and isodensity of the haematomas larger than 3 cm (73%), hydrocephalus (45%) and intraventricular haemorrhage (40%). Smaller haematomas without CT scan evidence of obliteration of the brain-stem cisterns or hydrocephalus had a better outcome.

Clinician’s Biases toward Surgery in Cerebellar Hematomas: An Analysis of Decision-Making in 94 Patients

“…However, no evidence exists that outcome in elderly patients following a cerebellar hematoma is particularly poor, and thus, it may be premature in the elderly patient to conclude that decompressive craniectomy and hematoma evacuation are unrealistic interventions. This observation may partially explain the close association of old age with poor outcome in several earlier studies in smaller groups of patients with cerebellar hematoma [5, 12]. …”

“…Important clinical variables might be age, deterioration in clinical condition, coma, and at the extreme, clinical signs of pontine compression, such as a forced gaze and pinpoint pupils [10]. Neuroradiological features that may persuade neurosurgeons to evacuate the hematoma are size, presence of hydrocephalus and perhaps most commonly distortion of the brainstem [10, 11, 12, 13, 14]. Little et al [11]reported, after CT scan became in common use, that medical management can be considered when a hematoma is less than 3 cm in diameter, and obstructive hydrocephalus or ventricular extension is absent.…”

Recommendations for the Management of Intracranial Haemorrhage – Part I: Spontaneous Intracerebral Haemorrhage

“…Surprisingly good results have been reported with surgical evacuation of cerebellar haematomas, but the optimal timing has not been established, and there are no prospective RCTs of surgery in cerebellar haemorrhage. By contrast there is universal clinical agreement for ventricular drainage for hydrocephalus at any time after ictus [131]. For this reason ventricular drainage and evacuation of the cerebellar haematoma should be considered if hydrocephalus occurs or if haematomas are >2–3 cm in diameter, although advanced age and coma militate against favourable outcomes.…”

Stereotactic Evacuation and Fibrinolysis of Cerebellar Hematomas

“…Despite the advantage of early diagnosis by CT and the advances in microneurosurgical technique, the mortality rates were reduced signifi cantly and clinical deterioration occurred frequently in the course of the disease, regardless of the therapeutic regimen. Several authors [10][11][12] stressed the importance of the clinical symptoms for indicating prognosis and observed a rapid progressive deterioration in one group and a more benign stable course in another group; however, this differ ence did not correlate well with the extent of the hematoma in the CT [4,13]. The specific location of the hematoma within the cerebellum plays some role, so that a laterodorsal site promises, according to Sala zar et al [13], a better outcome.…”

“…Several authors [10][11][12] stressed the importance of the clinical symptoms for indicating prognosis and observed a rapid progressive deterioration in one group and a more benign stable course in another group; however, this differ ence did not correlate well with the extent of the hematoma in the CT [4,13]. The specific location of the hematoma within the cerebellum plays some role, so that a laterodorsal site promises, according to Sala zar et al [13], a better outcome. Of great importance are, consistent with our findings, CT features which Taneda et al [14] noted as the presence of cisternal compression, in particular of the quadrigeminal and vermian cistern.…”