PROGNOSTIC FACTORS IN THE TREATMENT OF CEREBELLAR HEMORRHAGE

A prospective study for the treatment of cerebellar haemorrhage was conducted in a non-selected group of 33 patients. All patients with cerebellar haemorrhage arriving at the Department of Neurosurgery at Homburg/Saar have been included in this study, also those in bad condition, with high risk factors, and the aged. All of them required intensive care respectively intensive supervision. The following management protocol has been established. I. Cases with small haemorrhage, in good clinical condition, without hydrocephalus and/or occlusion of the basal cisterns: intensive supervision, operative intervention only if they deteriorate into one of the following groups. II. Cases with hydrocephalus - even if not yet pronounced but without occluded basal cisterns and without major tonsillar herniation: pressure monitored ventricular drainage, which opens at 15 mm Hg and thus prevents higher CSF pressure developing. III. a): Cases with large haematoma, occluded basal cisterns and/ or tonsillar herniation, but without severe general risk factors, as a first step: pressure monitored ventricular drainage; as a second step, if they do not improve soon after the normalization of the ventricular pressure: open surgical evacuation of the haematoma, which also decompresses the posterior fossa. If present and possible, causative vascular malformations may be dealt with at the same session. III. b): Same intracranial situation, but patients with severe general risk factors: pressure monitored ventricular drainage only. IV. Cases with causative aneurysm or angioma, who initially had been treated conservatively or by ventricular drainage: secondary operation of the vascular malformation after stabilization of the general conditions. Overall mortality was 33%. For the 13 men - median age 58 (27-83) - the initial average Glasgow Coma Scale (GCS) grade was 9.2 and the median haematoma diameter 3.7 cm. For the 20 women - median age 53 (17-80) - the corresponding figures were 10.4 GCS and 3.4 cm. Of the 13 men 6 died (mortality 46%; total Karnofsky scale 37.6). Of the 20 women 5 died (mortality 25%; total Karnofsky scale 57.5). The worst prognosis related to patients with an additional intraventricular haemorrhage and men aged between 50 and 70 years with an admission GCS of less than 7 and occluded cisterns. Early loss of consciousness, additional ventricular bleeding, brain stem extension of the haemorrhage, occluded perimesencephalic cisterns and severe systemic disease - diabetes mellitus, liver cirrhosis from alcohol abuse with resulting coagulation disorders - were the main factors which led to unfavourable outcome. The results of our study, which are presented in detail in this paper, allow recommendations for our therapeutic strategy.