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

Abstract

Background and Purpose: No studies have examined clinical decision-making in cerebellar hemorrhages. Clinical and CT features may influence surgery in patients with a spontaneous cerebellar hematoma. One commonly accepted adage is to remove a clot when 3 cm or larger in axial diameter on presentation CT scan. It is possible that certain preferences impact on outcome. Methods: We analyzed 94 patients with spontaneous cerebellar hematomas between the years of 1973–1993. Thirty-one patients underwent suboccipital craniectomy and clot removal with or without ventriculostomy. Deterioration denoted worsening of consciousness, new brainstem signs, or presentation in coma. Statistical analysis was performed utilizing a tree-based model fitted by binary recursive partitioning. Ninety-five percent confidence intervals (CI) were calculated. Results: The overall probability of surgical intervention was 33% (CI 23–43%). The chance of surgery in stable patients was 7% (CI 2–20%). Neurologic deterioration was seen in 54 patients (57%) and increased the prospects of a surgical procedure (52%, CI 38–66%). Surgery was performed in all deteriorating patients with small hematomas (size <3 cm), but large clots (size >3 cm) did not substantially influence surgical decision-making (45%, CI 30–60%) except in patients younger than 70 years old (57%, CI 41–82%). Conclusions: Clinicians at our institution usually wait for clinical deterioration to unfold prior to operating on patients with cerebellar hematomas. After deterioration occurs, they prefer small hematomas but will operate on large hematomas when patients are younger than 70, generally withholding surgery from older patients. These attitudes may impact on outcome and should be considered in future treatment trials.

Long-Term Outcome after Spontaneous Cerebellar Haemorrhage

“…Similar to findings in patients with supratentorial haemorrhage and in accordance with the previous literature [1, 3, 10, 12, 18], arterial hypertension was the predominant aetiological factor, followed by coagulation disorders. Remarkably, in contrast to patients with supratentorial haemorrhage in whom cerebral amyloid angiopathy (CAA) is the cause in about 10% of all patients [25], CAA was infrequently diagnosed in our patient population: of course, CAA could have been underdiagnosed in the medically treated patients, in whom no pathological examination was performed.…”

“…Moreover, the time delay between initial evaluation and haematoma evacuation was short. In contrast to other treatment protocols, which suggest that the indication for haematoma evacuation should only be established after clinical deterioration [12, 29, 30], we performed haematoma evacuation as soon as possible. As a result, most patients were not in a critical condition before surgery (median GCS score 14) and the unfavourable long-term outcome in these patients cannot be explained with a desperate initial state.…”

“…Because controlled studies are lacking, the optimum medical management as well as indications for surgery (including osteoplastic haematoma evacuation, needle aspiration or decompressive surgery of the posterior fossa with or without ventricular drainage) are still a matter of debate [1, 12, 13]. Specific medical treatment options beyond the basic measures of life support and general intensive care are not established.…”

Clinical and radiographic predictors of neurological outcome following posterior fossa decompression for spontaneous cerebellar hemorrhage

“…5 Spontaneous cerebellar hemorrhage is a disease that affects the elderly population. 9 Clinical and radiographic predictors of postoperative neurological exam and outcome are not widely addressed in the current literature. These predictors might prove valuable not only in tailoring management and decision making, but also in predicting prognosis after suboccipital decompression and clot evacuation.…”

Critical care of intracerebral and subarachnoid hemorrhage

“…An ongoing surgical trial in intracerebral hemorrhage (STICH), a multicenter, international randomized trial, will attempt to clarify whether surgical therapy is beneficial in ICH. Evacuation practices at individual centers for treatment of cerebellar hemorrhages may vary, but in general, indications for surgery include compression of nearby structures (ie, fourth ventricle or brainstem) and/or hematoma of large size (ie, 3 cm 3 or more on CT scan) [48]. Stereotactic-guided catheter evacuation with thrombolysis shows promise as an alternative to surgical evacuation in the treatment of ICH [49••].…”