Posterior fossa is a shallow space accommodating brainstem and cerebellum. Bleed in the cerebellum can cost life as it leads to rapid deterioration by hydrocephalus and upward herniation.

1. cka
SURESH BISHOKARMA, MS
MCH RESIDENT, NEUROSURGERY
NINAS
CEREBELLAR HAEMATOMA

2. Cerebellum is 140cm3.

3. Volumes of the
Posterior Cranial Fossa, Cerebellum
Vurdem ÜE, Acer N, Ertekin T, Savranlar A, İnci MF. Analysis of the Volumes of the Posterior Cranial Fossa, Cerebellum, and
Herniated Tonsils Using the Stereological Methods in Patients with Chiari Type I Malformation. The Scientific World Journal.
2012;2012:616934

5. ARTERIAL SUPPLY OF CEREBELLUM

8. LIFE THREATENING CONDITION
CEREBELLAR BLEED

9. *10–15% of all ICH
*High mortality: 48 hours

10. *Hypertension: 60-80%
*AVM and Cavernoma
*Anticoagulants and blood dyscrasis
*Trauma
*Neoplasm
*Aneurysm
*Amyloid: rare
*Remote cerebellar hemorrhage
Aetiology

11. In hypertensive patients : Rupture of cerebellar microaneurysms.
Pathophysiology
Charcot and Bouchard

12. Blood flow current
Dentate nucleus
Cerebellar
hemisphere and
cross midline or
Cerebellar
peduncle or
rupture into the
fourth ventricle.
Brain stem
compressive

13. Early
* Vomiting, headache, ataxia
Clinical feature
Dentate nucleus
Cerebellar
hemisphere and
cross midline or
Cerebellar
peduncle or
rupture into the
fourth ventricle.
Brain stem
compressive
Early
Intermediate
Late

14. *Hydrocephalus
Confused, agitate or drowsy.
*VI nerve palsy: Dorsal portion of brainstem.
Intermediate stage
Dentate nucleus
Cerebellar
hemisphere and
cross midline or
Cerebellar peduncle
or rupture into the
fourth ventricle.
Brain stem
compressive

15. *Ipsilateral gaze paresis: Horizontal gaze centres.
*Facial paresis: Facial colliculus
*Horner’s syndrome: Sympathetic pathway running from
the hypothalamus through the dorsal brain stem.
*Hemiparesis: Pyramid
*Stupur coma and decerebrate
*Pinpoint pupil®:Descending sympathetic pathways from
hypothalamus to cervical cord is affected. Parasympathetic
control of pupil in midbrain is preserved
*Medullary involvement: Cardiovascualar instability and
ataxic respiration or apnoea .
Late
Dentate nucleus
Cerebellar
hemisphere and
cross midline or
Cerebellar peduncle
or rupture into the
fourth ventricle.
Brain stem
compressive

16. *Hydrocephalus,
*Direct brainstem compression by the hematoma and
surrounding swelling, or both.
Depressed GCS:
Dentate nucleus
Cerebellar
hemisphere and
cross midline or
Cerebellar peduncle
or rupture into the
fourth ventricle.
Brain stem
compressive

17. Brainstem compression
Upwards herniation through the tentorial incisura or
Downward tonsillar herniation through the foramen
magnum.
Death
Dentate nucleus
Cerebellar
hemisphere and
cross midline or
Cerebellar peduncle
or rupture into the
fourth ventricle.
Brain stem
compressive

18. WORK UP

19. *Critical care: BP control and respiratory support
*Investigation
*Imaging
Management include

20. CT scan head
CTA
MRI with MRA
DSA
IMAGING
• Location of hemorrhage ( vermian, hemispheric or both)
• Size of hemorrhage
• IVE
• Invasion into brain stem
• Presence of hydrocephalus
• Sign of brain stem impairment
• Presence and extent of perilesional edema
• Evidence of tight posterior fossa (TPF): Weisberg

21. EVIDENCE OF TIGHT POSTERIOR FOSSA (TPF)
WEISBERG 1986
14 patients
WEISBERG 1986;14 PATIENTS

22. TREATMENT

23. *GCS
*Cerebellar atrophy
*Size and Volume of hematoma
*Hydrocephalus
*Degree of basal cisternal compression
*Brain stem sign
*Location of the hematoma
*Anatomy of posterior fossa
DECISION

24. *Controversial
*Surgical evacuation of the hematoma
*External ventricular drainage
*Conservative treatment.

25. *Outcomes after nonsurgical management were variable, with mortality
rates between 9 and 75%.

26. *Posterior fossa craniectomy and evacuation of the hematoma are not
without risks.
*Postoperative recurrent hemorrhage can be fatal

27. *In one series, the presence of hydrocephalus invariably resulted from
brainstem compression and it was suggested that the presence of
hydrocephalus necessitated a posterior fossa craniectomy and evacuation
of the hematoma.
Mathew P, Teasdale G, Bannan A, Oluoch-Olunya D: Neurosurgical management of cerebellar haematoma and
infarct. J Neurol Neurosurg Psychiatry 59:287–292, 1995.

28. *Ventricular drainage alone was observed to be ineffective in some cases.
*Outcomes after nonsurgical management were variable, with mortality
rates between 9 and 75%. affirmed

29. *When surgery is indicated
*controversy exists regarding whether ventricular drainage only,
evacuation of the hematoma, or both procedures should be performed.
*Some surgeons recommend drainage of hydrocephalus as the only or initial
procedure in all cases.
*Others recommend evacuation of the hematoma whenever surgery is
indicated.
Current management

30. Size and volume
Cisterns
Hydrocephalus
Brain stem size
Consciousness
Surgical evacuation: Indication

31. *GCS 14 or 15 and < 3 cm : Conservatively
*GCS scores of 13 or less and ≥ 3 cm: surgery
*Clot size between 2-3cms, if level of consciousness has altered, should be
considered.
Size of hematoma
Kobayashi et al; 52 patients

32. 3 to 4 cm or
a volume of more than 15 ml :
Surgical evacuation of the hematoma.
Kobayashi et. Al. Treatment of hypertensive cerebellar hemorrhage: Surgical or conservative management?
Neurosurgery 34:246–251, 1994.

33. *Size threshold
– 3 cm vs. 4 cm
*Radiographic evidence of brainstem compression
*Accounts for edema
*Clinical examination

34. *Patient with hematoma size of >70cm3 did not respond to any treatment
and died within 48hrs.

35. Timing of Surgical Intervention
“Prophylactic” vs. at time of deterioration
ISSUES TO CONSIDER

36. *Quadrigeminal cistern into 3 groups:
*Grade I (normal),
*Grade II (compressed),
*Grade III (absent).
*Good outcomes:
*Grade I: 88%,
*Grade II: 69%,
*Grade III: 0%
CISTERNS
Taneda et al. 75 Patients

37. *The appearance of the fourth ventricle was divided into 3 groups:
*Grade I (normal size and configuration),
*Grade II (partially compressed and shifted)
*Grade III (completely obliterated).
4th ventricle
Kirollos et al. 50 patients

38. *Studied in 25 patients with cerebellar bleed.
*Stable Grade I and II: Conservatively.
*Grade I or II compression : only ventricular drainage
*15 (60%) Grade I or II compression did not require clot evacuation.
*Acute deterioration to comatose state occurred in 6 (43%) of the 14
patients with Grade III compression who were conscious at presentation;
none of them experienced good outcomes.
Kirollos et al

39. BEST
*Glasgow coma scale score of
14 or greater
*Small hemorrhage (< 30 mm )
*Without hydrocephalus
*Without basal cistern
effacement
CRITERIA FOR MEDICAL
CONSERVATIVE TREATMENT
WORST
*Comatose
*Flaccid
*Without brainstem reflexes
*Large midline hemorrhage

40. *Stereotactic aspiration,
*Endoscopic bur hole evacuation,
*Local infusion of a thrombolytic agent : TPA
Other modalities

41. 1. Low GCS at admission
2. Obliteration of 4th ventricle and peri-mesenchephalic cistern.
3. Hydrocephalus
4. T2W MRI: high signal intensity in brain stem
PROGNOSIS

42. MANAGEMENT ALGORITHM
Kirollos RW et al. Management of spontaneous cerebellar hematomas: a prospective treatment protocol. Neurosurgery.2001;49(6):1378-86.
4th Ventricle
Kirollos’s grade
I
GCS <13
CONSERVATIVE CSF- D
II
GCS >13
CONSERVATIVE
GCS <13
HYDROCEPHALUS
YES
CSF-D
IMPROVEMENT NO IMPROVEMENT
EVACUATE CLOT
NO
EVACUATE
III
ANY GCS
EVACUATE CLOT +
CSF D
CSF-D: EVD or VPshunt.

43. CEREBELLAR HAEMATOMA NINAS