Controversies in the Neurosurgical Management of Cerebellar Hemorrhage and Infarction

Arun Paul Amar, M.D.


Neurosurg Focus. 2012;32(4):e1 

In This Article

Abstract and Introduction


Evidence-based guidelines for the management of hemorrhagic and ischemic cerebellar stroke are sparse, and most available data come from Class III studies. As a result, opinions and practices regarding the nature and role of neurosurgical intervention vary widely. A comprehensive literature review was conducted to adjudicate several contentious issues, such as the difference in the management of cerebellar hemorrhage versus infarction, criteria for imaging to exclude an underlying structural lesion, the value of MRI for patient selection, the role of external ventricular drainage, the indications for operative management, the timing of surgical intervention, and various options of surgical technique, among others. Treatment algorithms proposed in several different studies are compared and contrasted. This analysis is concluded by a summary of the recommendations from the American Stroke Association, which advises that patients with cerebellar hemorrhage who experience neurological deterioration or who have brainstem compression and/or hydrocephalus due to ventricular obstruction should undergo surgical evacuation of the hemorrhage as soon as possible, and that initial treatment of such patients with ventricular drainage alone rather than surgical removal of the hemorrhage is not recommended.


The management of cerebellar hemorrhage has endured controversy ever since Sir Charles Ballance reported the first successful surgical evacuation in 1906.[2] Institutional and individual variations abound in the management of cerebellar hemorrhage. To a degree, this debate is due to the relatively flimsy quality of the medical literature in support of different practices. For instance, in advocating against external ventricular drainage alone in the treatment of patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction, the American Stroke Association relies on evidence rated as Level C, the weakest category in effect at the time (consensus opinion of experts, case studies, or standard of care).[24] Similarly, their prior recommendation that angiography is not required for older, hypertensive patients with cerebellar hemorrhage in whom CT findings do not suggest a structural lesion is based upon Level V evidence, the weakest category in effect at the time (data from anecdotal case series only).[4]

Several randomized trials comparing early surgery with initial conservative management for ICH have been conducted, including the recent Surgical Trial in Intracerebral Hemorrhage (STICH).[23] Overall, these studies have largely shown no benefit to surgery, although post hoc subgroup analysis reveals some exceptions. Patients with cerebellar ICH have been excluded from all these randomized trials, because clinical equipoise was not believed to be present.[24] As one expert commented about the related condition of cerebellar infarction, "the results of surgery have been so consistently favorable in patients who clearly were progressively deteriorating that it seems fair to say that this is one surgical indication that does not need the scrutiny of a randomized study."[12]

As a result of these biases, data principally consist of uncontrolled, single institution retrospective case series (Class III evidence). Collectively, however, these reports suggest that the benefit of surgery is not so straightforward. Donauer et al.[7] reviewed 21 papers from 1958 to 1993 and performed a meta-analysis comparing medical versus operative treatment of cerebellar ICH. In the cohort of 357 patients who underwent surgery, the mortality rate was 49%, while that in the 269 patients treated conservatively was 50%. Similarly, Hankey and Hon[10] reviewed 8 prior series of surgery for infratentorial hemorrhage comprising a total of 405 patients. One study suggested overall benefit, while 2 studies reported benefit only in certain subgroups (conscious or drowsy but deteriorating patients), and the remaining 5 studies were either inconclusive or showed no benefit of surgery.

In an effort to provide more concreteness to this issue and to elucidate related concepts in the management of cerebellar hemorrhage and infarction, this article reviews relevant studies from the past century. It begins with an overview of the pathogenesis and natural history, which form the foundation and rationale for all treatment. Next, 9 separate areas of controversy are explored in detail. The review concludes with a summary of the recommendations from the American Stroke Association, whose position statements have evolved considerably from their first publication in 1999 to 2010.[3,4,24]


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