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.
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
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
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
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
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
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
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.
PICA: posterior part of cerebellar hemisphere b. inferior vermis c. central nuclei of cerebellum
AICA: the anterior inferior quarter of the cerebellum. b. the middle cerebellar peduncle,
SCA: most of the cerebellar cortex, b. the cerebellar nuclei, and c. The superior cerebellar peduncles
PICA: posterior part of cerebellar hemisphere b. inferior vermis c. central nuclei of cerebellum
AICA: the anterior inferior quarter of the cerebellum. b. the middle cerebellar peduncle,
SCA: most of the cerebellar cortex, b. the cerebellar nuclei, and c. The superior cerebellar peduncles
Spontaneous cerebellar hematomas represent approximately 10%–15% of all ICH
High mortality
Charcot–Bouchard aneurysms (also known as miliary aneurysms or microaneurysms) are aneurysms of the brain vasculature which occur in small blood vessels (less than 300 micrometre diameter).
The symptoms produced by cerebellar hemorrhage are related to destruction and compression of the cerebellum itself or to the subarachnoid hemorrhage resulting from rupture of the hematoma into the subarachnoid space.
Hydrocephalus result from the compression of the 4th ventricle or rupture of hemorrhage into ventricle.
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
Pupil: Constrict ® : Descending sympathetic pathways from hypothalamus to cervical cord is affected. Parasympathetic control of pupil in midbrain is preserved until late
Late: Stupur coma and decerebrate.
Medullary involvement: Cardiovascualar instability and ataxic respiration or apnoea .
Furthermore, estimation of the size of the hematoma on the basis of CT scans could be both difficult and inaccurate, because of the nebulous margins at the interface between the hematoma and the surrounding cerebellum.
The mass effect produced by areas of surrounding edema could be underestimated.
MRI is not superior to CT to delinate Haematoma. But it may be superior to analyse the other brainstem pathology.
TPF: CT: Effacement of basal cisterns of posterior fossa and ventricular enlargement consistent with obstructive hydrocephalus.
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)
WEINGBERG 14 PATIENTS: EFFACEMENT OF BASALCISTERN AND OBSTRUCTIVE HYDROCEPHALUS: PATIENT WITH TPF SHOWED RAPID DETERIORATION.
The degree of cerebellar atrophy (considering the advanced age of most patients with cerebellar hemorrhage) should be evaluated.
A large hematoma may not exert significant brainstem compression in the presence of cerebellar atrophy.
Outcomes after nonsurgical management were variable, with mortality rates between 9 and 75%, because surgery was not attempted for patients considered to be at high risk in many series, whereas primarily patients in good neurological condition were included in other series.
Indication are based on level of consciousness, clinical course, size of hematoma.
typically 3 or 4 cm, above which they recommend surgical evacuation of the hemorrhage regardless of clinical status
INDICATION:
3.5X 2.5CM VERMIAN HEMATOMA OR 4X3 CM HEMISPHERIC.
BECAUSE VERMIAN LIES CLOSER TO THE BRAIN STEM AND CSF PATHWAY.