Spontaneous cerebellar hemorrhage carries a grim prognosis in both operated and unoperated patients.

Management of spontaneous cerebellar hemorrhage (SCH) has been scarcely reported, and controversies still exist regarding their surgical management. METHODS: We performed a retrospective review of the Rambam Medical Center registry. All cases with a SCH, operated or not, were reviewed. Basic patient parameters, clinical status on admission and imaging results, management and outcome measures were evaluated. Parameters were compared between the operated and unoperated groups, and assessed for their correlation to patient death within 12 months. When operated, patients underwent Suboccipital craniectomy (SOC), insertion of an external ventricular drain (EVD) or both. RESULTS: 57 patients were treated for SCH in the years 2005-2017. 20 patients (35.09%) died during their original admission. 16 were discharged in non-functional status. In total, 36 patients died within 12 months of their admission. Only 21 patients (36.84%) were alive one year after their bleed. The following parameters were correlated to death in the entire cohort: older age, larger hematoma size, hydrocephalus, brainstem compression by the bleed and outcome status. The unoperated patients were younger, and had a lower Glasgow Coma Scale (GCS) on admission. Death within 12 months occurred in 69.77% of the operated patients, but only 42.86% of the unoperated patients, p = 0.10. Unfavorable outcome was found in 36% of the unoperated group and 72% of the operated group, p = 0.024. CONCLUSION: SCH carries a grim prognosis in both operated and unoperated patients. Roughly one third of patients in our series died during their admission and another third were either vegetative or severely disabled on discharge.

Intracranial hemorrhage type and same-admission mortality in patients with left ventricular assist devices.

OBJECTIVES: Left ventricular assist devices (LVAD) provide mechanical circulatory support for patients with advanced heart failure. Intracranial hemorrhage in this population represent a significant management challenge. The objective of this study is to report our initial experience on same-admission outcomes with LVAD patients that presented with various types of intracranial hemorrhage (ICH). PATIENTS AND METHODS: A retrospective review of a large volume center over a two-year period was performed. LVAD patients with ICH requiring a neurosurgical consultation were identified. Hemorrhage type, interventions, discharge disposition and cause of death were recorded. RESULTS: 27 LVAD patients with ICH received a neurosurgical consultation. The average INR at the time of ICH was 2.7 (1.0-8.8). Hemorrhage types seen were lobar (10/27, 37 %), SAH (5/27, 19 %), SDH (4/27, 15 %), cerebellar ICH (3/27, 11 %), multiple ICH (3/27, 11 %), and hemorrhagic conversion (2/27, 7 %). The overall mortality rate was 48.2 % (13/27), with the highest mortality being in those patients who had multiple ICH at the time of presentation (3/3, 100 %). The majority of patients with ICH (85.2 %) were non-operative. Lobar IPH was <3 cm in 80 % (8/10) of these, and 6/8 (75 %) ultimately died. 11 %(3/27) received surgical intervention. Of these, 67 % ultimately withdrew care. 77 % (10/13) of patients died as a result of the ICH. 80 % of patients with SAH were ultimately discharged home. CONCLUSIONS: Patients with a LVAD and ICH have a high rate of same-admission mortality (48 %). Hemorrhage location, intra-axial or extra-axial, resulted in patients being a risk for death secondary to either the hemorrhage itself or pump thrombosis, respectively.

The CHOPIn Study: a Multicenter Study on Cerebellar Hemorrhage and Outcome in Preterm Infants.

Cerebellar hemorrhage (CBH) is a frequent complication of preterm birth and may play an important and under-recognized role in neurodevelopment outcome. Association between CBH size, location, and neurodevelopment is still unknown. The main objective of this study was to investigate neurodevelopmental outcome at 2 years of age in a large number of infants with different patterns of CBH. Of preterm infants (≤ 34 weeks) with known CBH, perinatal factors, neuro-imaging findings, and follow-up at 2 years of age were retrospectively collected. MRI scans were reassessed to determine the exact size, number, and location of CBH. CBH was divided into three groups: punctate (≤ 4 mm), limited (> 4 mm but < 1/3 of the cerebellar hemisphere), or massive (≥ 1/3 of the cerebellar hemisphere). Associations between pattern of CBH, perinatal factors, and (composite) neurodevelopmental outcome were assessed. Data of 218 preterm infants with CBH were analyzed. Of 177 infants, the composite outcome score could be obtained. Forty-eight out of 119 infants (40%) with punctate CBH, 18 out of 35 infants (51%) with limited CBH, and 18 out of 23 infants (78%) with massive CBH had an abnormal composite outcome score. No significant differences were found for the composite outcome between punctate and limited CBH (P = 0.42). The risk of an abnormal outcome increased with increasing size of CBH. Infants with limited CBH have a more favorable outcome than infants with massive CBH. It is therefore important to distinguish between limited and massive CBH.

Minimally Invasive Evacuation of Spontaneous Cerebellar Intracerebral Hemorrhage.

OBJECTIVE: Spontaneous cerebellar intracerebral hemorrhage (scICH) constitutes ∼10% of all cases of spontaneous ICH, with a mortality of 20%-50%. Suboccipital craniectomy (SOC) is commonly performed for scICH causing brainstem compression or hydrocephalus. However, SOC requires long anesthesia times and results in a high complication rate. We present a series of patients who minimally invasive scICH evacuation as an alternative to traditional SOC. METHODS: We retrospectively reviewed the operative records for patients presenting to a single center from January 1, 2009 to March 1, 2017. All patients who had undergone evacuation of scICH were included in the present study. Clinical and radiographic variables were collected, including admission and postoperative Glasgow coma scale (GCS) scores, preoperative and postoperative hematoma volumes, and modified Rankin scale (mRS) scores at long-term follow-up. RESULTS: We identified 10 patients who had presented with scICH requiring surgery. All scICH evacuations were performed through a minicraniectomy positioned in the suboccipital area as close to the hematoma as possible. The mean patient age was 64.1 years. The mean presenting GCS score was 8.6, the mean initial hematoma volume was 25.4 mL, the mean procedure time was 57 minutes, and the mean postoperative hematoma volume was 2.8 mL. The mortality rate was 10% and mean long-term follow-up mRS score was 2. CONCLUSIONS: Minimally invasive scICH hematoma evacuation is a feasible alternative to SOC with numerous advantages that could lead to improved radiographic and clinical results.

The Unique Features and Outcomes of Microsurgically Resected Cerebellar Arteriovenous Malformations.

BACKGROUND: Cerebellar arteriovenous malformations (CAVMs) are challenging to treat given their close proximity to the brain stem, greater propensity for rupture, and greater rates of morbidity and mortality than other brain arteriovenous malformations. The present investigation sought to describe and characterize the features of these rare and unique lesions. METHODS: A retrospective review of CAVM cases treated at 2 tertiary medical centers was performed. Patients surgically treated at institution 1 from September 1999 to February 2013 and institution 2 from October 2008 to October 2015 were included. RESULTS: A total of 120 patients had been treated. Of the 120 patients, 85 (70.8%) had initially presented with hemorrhage, 45 (37.5%) of whom experienced hemorrhage requiring emergent surgery. A favorable neurological outcome was observed in 76 patients (63.3%; modified Rankin Scale score <3). The perioperative mortality was 2.5% (n = 3). The long-term mortality rate was 7.5% (n = 9). The mean follow-up time was 1.82 years. On average, the patients with large CAVMs (≥3 cm; P ≤ 0.001), who had received embolization before surgery (P = 0.04), did not have an associated aneurysm (P ≤ 0.001), or had a residual CAVM after surgery (P = 0.008) were significantly younger. Female patients had fewer CAVMs with deep venous drainage (54.3% vs. 72.3%; P = 0.049), experienced decreased mortality (1.4% vs. 16.7%; P = 0.003), and were less likely to have worse neurological status after treatment (P = 0.003). CONCLUSIONS: CAVMs are rare lesions that exhibit unique disease characteristics. Although most patients will experience a favorable outcome, CAVMs frequently present with hemorrhage, result in high rates of morbidity and mortality, and characteristically differ depending on patient age and gender.

Prediction of a multiple sclerosis diagnosis in patients with clinically isolated syndrome using the 2016 MAGNIMS and 2010 McDonald criteria: a retrospective study.

BACKGROUND: In 2016, the Magnetic Resonance Imaging in Multiple Sclerosis (MAGNIMS) network proposed modifications to the MRI criteria to define dissemination in space (DIS) and time (DIT) for the diagnosis of multiple sclerosis in patients with clinically isolated syndrome (CIS). Changes to the DIS definition included removal of the distinction between symptomatic and asymptomatic lesions, increasing the number of lesions needed to define periventricular involvement to three, combining cortical and juxtacortical lesions, and inclusion of optic nerve evaluation. For DIT, removal of the distinction between symptomatic and asymptomatic lesions was suggested. We compared the performance of the 2010 McDonald and 2016 MAGNIMS criteria for multiple sclerosis diagnosis in a large multicentre cohort of patients with CIS to provide evidence to guide revisions of multiple sclerosis diagnostic criteria. METHODS: Brain and spinal cord MRI and optic nerve assessments from patients with typical CIS suggestive of multiple sclerosis done less than 3 months from clinical onset in eight European multiple sclerosis centres were included in this retrospective study. Eligible patients were 16-60 years, and had a first CIS suggestive of CNS demyelination and typical of relapsing-remitting multiple sclerosis, a complete neurological examination, a baseline brain and spinal cord MRI scan obtained less than 3 months from clinical onset, and a follow-up brain scan obtained less than 12 months from CIS onset. We recorded occurrence of a second clinical attack (clinically definite multiple sclerosis) at months 36 and 60. We evaluated MRI criteria performance for DIS, DIT, and DIS plus DIT with a time-dependent receiver operating characteristic curve analysis. FINDINGS: Between June 16, 1995, and Jan 27, 2017, 571 patients with CIS were screened, of whom 368 met all study inclusion criteria. At the last evaluation (median 50·0 months [IQR 27·0-78·4]), 189 (51%) of 368 patients developed clinically definite multiple sclerosis. At 36 months, the two DIS criteria showed high sensitivity (2010 McDonald 0·91 [95% CI 0·85-0·94] and 2016 MAGNIMS 0·93 [0·88-0·96]), similar specificity (0·33 [0·25-0·42] and 0·32 [0·24-0·41]), and similar area under the curve values (AUC; 0·62 [0·57-0·67] and 0·63 [0·58-0·67]). Performance was not affected by inclusion of symptomatic lesions (sensitivity 0·92 [0·87-0·96], specificity 0·31 [0·23-0·40], AUC 0·62 [0·57-0·66]) or cortical lesions (sensitivity 0·92 [0·87-0·95], specificity 0·32 [0·24-0·41], AUC 0·62 [0·57-0·67]). Requirement of three periventricular lesions resulted in slightly lower sensitivity (0·85 [0·78-0·90], slightly higher specificity (0·40 [0·32-0·50], and similar AUC (0·63 [0·57-0·68]). Inclusion of optic nerve evaluation resulted in similar sensitivity (0·92 [0·87-0·96]), and slightly lower specificity (0·26 [0·18-0·34]) and AUC (0·59 [0·55-0·64]). AUC values were also similar for DIT (2010 McDonald 0·61 [0·55-0·67] and 2016 MAGNIMS 0·61 [0·55-0·66]) and DIS plus DIT (0·62 [0·56-0·67] and 0·64 [0·58-0·69]). INTERPRETATION: The 2016 MAGNIMS criteria showed similar accuracy to the 2010 McDonald criteria in predicting the development of clinically definite multiple sclerosis. Inclusion of symptomatic lesions is expected to simplify the clinical use of MRI criteria without reducing accuracy, and our findings suggest that needing three lesions to define periventricular involvement might slightly increase specificity, suggesting that these two factors could be considered during further revisions of multiple sclerosis diagnostic criteria. FUNDING: UK MS Society, National Institute for Health Research University College London Hospitals Biomedical Research Centre, Dutch MS Research Foundation.

Suboccipital Decompressive Craniectomy for Cerebellar Infarction: A Systematic Review and Meta-Analysis.

BACKGROUND: Suboccipital decompressive craniectomy (SDC) for cerebellar infarction has been traditionally performed with minimal high-quality evidence. The aim of this systematic review and meta-analysis is to investigate the impact of SDC on functional outcomes, mortality, and adverse events in patients with cerebellar infarcts. METHODS: A systematic review and meta-analysis in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Our primary outcome was the proportion of patients with moderate-severe disability after SDC. Secondary outcomes included mortality and adverse events. A sensitivity analysis was conducted to examine the roles of age, preoperative neurologic status, external ventricular drain insertion, and debridement of infarcted tissue on SDC outcomes. RESULTS: Eleven studies (with 283 patients) met our inclusion criteria. The pooled event rate for moderate-severe disability was 28% (95% confidence interval [CI], 20%-37%) and for mortality, it was 20% (95% CI, 12%-31%). The estimated overall rate of adverse events for SDC was 23% (95% CI, 14%-35%). Sensitivity analysis found less mortality with mean age <60 years, higher rates of concomitant external ventricular drain insertion, and debridement of infarcted tissue. Several factors were identified for heterogeneity between studies, including follow-up time, outcomes scale, extent of infarction, and other neuroimaging features. CONCLUSIONS: The best available evidence for SDC is based on retrospective observational studies. SDC for cerebellar infarction is associated with better outcomes compared with decompressive surgery for hemispheric infarctions. Lack of standardized reporting methods for SDC is a considerable drawback to the development of a better understanding of the impact of this surgery on patient outcomes.

Surgery for Cerebellar Hemorrhage: A National Surgical Quality Improvement Program Database Analysis of Patient Outcomes and Factors Associated with 30-Day Mortality and Prolonged Ventilation.

OBJECTIVE: Primary cerebellar hemorrhage accounts for 10% of all intracranial hemorrhages. Given the confined space of the posterior fossa, cerebellar hemorrhage management sometimes necessitates suboccipital decompression and hematoma evacuation. In this study, we examine outcomes after surgery for primary cerebellar hemorrhage and identify risk factors associated with adverse outcomes. METHODS: A retrospective review of the 2005-2014 American College of Surgeons-National Surgical Quality Improvement Program database was performed, with Current Procedural Terminology Code 61315 (suboccipital craniectomy or craniotomy for evacuation of cerebellar hemorrhage) queried between 2005 and 2014. Patient demographics, preoperative comorbidities, and 30-day outcomes were analyzed. Univariate and multivariate regression analyses were performed to identify predictors of mortality and adverse events. RESULTS: A total of 158 craniotomies were studied, with a 30-day mortality rate of 26.6%. The most common adverse events included ventilator dependence after 48 hours (48.7%) and pneumonia (24.1%). Almost one quarter (24.7%) of patients required additional operations, with 8.5% of patients undergoing repeat craniotomy. Death was associated with premorbid dependent functional status (P = 0.005), American Society of Anesthesiologists class (P = 0.010), and history of congestive heart failure (P = 0.031). Prolonged ventilation was associated with premorbid functional status (P = 0.043) and ventilator dependence (P = 0.007) before surgery. CONCLUSIONS: Cerebellar hemorrhage is associated with significant risk of mortality and ventilator dependence. In patients who require surgery, 30-day mortality risk remains high (26.6%), with functional status and American Society of Anesthesiologists class predictive of death.

Microsurgery and endovascular treatment of posterior inferior cerebellar artery aneurysms.

Aneurysms located on the posterior inferior cerebellar artery are rare, and treatment guidelines for them have not yet been established. In this paper, we present the results of a retrospective study which analyzes the management and treatment of 15 patients with posterior inferior cerebellar artery aneurysms from 2004 to 2013. The aneurysms were ruptured and presented with a subarachnoid hemorrhage. Of the 15 aneurysms, ten were of saccular, three fusiform, and two were dissecting. Computed tomography angiography or digital subtraction angiography revealed other aneurysms or intracerebral artery hypoplasia in seven patients. Either surgical or endovascular treatment was performed depending on the localization and morphology of the aneurysm. Six aneurysms were coiled, and surgery was performed in nine cases. Of the nine surgically treated patients, six (75%) had good outcomes. Of the six patients treated using endovascular procedures, three patients (50%) recovered. Patient outcomes were classified using the Hunt&Hess scale. Patients with Hunt&Hess 1-3 recovered without a neurological deficit. On the other hand, patients with Hunt&Hess 4-5 had a risk of up to 93% of death or a poor outcome. In two cases of endovascular and in two cases before any therapy, aneurysmal rebleeding occurred and resulted in deterioration of clinical state of the patient and a poor prognosis with high risk of death. This study shows the necessity of acute treatment of posterior inferior cerebellar artery aneurysm, of thorough diagnostic, and of interdisciplinary cooperation.

Survival in synucleinopathies: A prospective cohort study.

OBJECTIVES: Parkinson disease (PD), multiple system atrophy (MSA), and pure autonomic failure (PAF) involve cytoplasmic deposition of α-synuclein and are considered to be synucleinopathies. Approximately 40% of patients with PD, most patients with MSA, and all patients with PAF have neurogenic orthostatic hypotension (OH). This study compared long-term survival in these synucleinopathies. METHODS: In this prospective cohort study, survival data were obtained for 97.6% of 206 referred patients evaluated between 1994 and 2014 (47 PD + OH, 54 PD no OH, 15 cerebellar MSA [MSA-C], 57 parkinsonian MSA [MSA-P], 28 PAF). Individual diagnoses were confirmed by clinical criteria and results of pharmacologic, neurochemical, and neuroimaging tests of sympathetic noradrenergic innervation. The Cox proportional hazard model was used to calculate hazard ratios (HRs) from symptom onset and from time of evaluation to death. RESULTS: Patients with MSA-C or MSA-P had shorter survival from symptom onset than did patients with PD + OH (age- and sex-adjusted HR = 6.1, 5.6; p < 0.0001 each), PAF (HR = 10.8, 9.9; p < 0.0001 each) or PD no OH (HR = 14.9, 13.6; p < 0.0001 each). Among parkinsonian patients who died, median times from motor onset to death were 7.5 years in MSA-P, 11.6 years in PD + OH, and 15.8 years in PD no OH. Probabilities of survival for 10 years from onset of relevant symptoms were 0.39 in MSA-C, 0.33 in MSA-P, 0.74 in PD + OH, 0.87 in PAF, and 0.93 in PD no OH. CONCLUSIONS: In synucleinopathies, survival depends on the particular disease, with the risk of death greater in MSA-P than in PD + OH and in PD + OH than in PD no OH.

The Predictor of Mortality within Six-Months in Patients with Spontaneous Cerebellar Hemorrhage: A Retrospective Study.

BACKGROUND AND PURPOSE: The mortality rate of cerebellar hemorrhage (CH) is generally higher than other types of intracranial hemorrhage. Recently, the increased survey rate of CH has come from improved clinical imaging and earlier surgical intervention. Hence, the predictors of intermittent- (1 to 6 months) and long-term (> 6 months) mortality are clinically practical use for educational and therapeutic decisions. Unfortunately, the factors predictive mortality within six-month had not yet been systematically investigated. METHODS: Seventy-two patients with acute spontaneous CH were retrospectively analyzed. The patients were divided into the six-month mortality group (n = 21, died within 6 months after CH onset) and survival group (n = 51, survived beyond 6 months). The independent predictors of six-month mortality were investigated by multivariate Cox proportional hazards regression. RESULTS: The radiological brainstem compression (hazard ratios = 23.5; p < 0.001) was independent predictor of mortality within six-month after CH onset. The median onset time of six-month mortality was 5 days in patients with brainstem compression (p < 0.001) and the hazard ratios for the onset time was 13.1 compared with those without brainstem compression (95% CI, 4.7 to 36.3, p < 0.001). CONCLUSIONS: We report the first study that radiological brainstem compression predicted the mortality within six-month after onset of CH. Patients with radiological brainstem compression were about 23 times more likely to die within 6 months after CH than those without radiological brainstem compression.

Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association.

BACKGROUND AND PURPOSE: There are uncertainties surrounding the optimal management of patients with brain swelling after an ischemic stroke. Guidelines are needed on how to manage this major complication, how to provide the best comprehensive neurological and medical care, and how to best inform families facing complex decisions on surgical intervention in deteriorating patients. This scientific statement addresses the early approach to the patient with a swollen ischemic stroke in a cerebral or cerebellar hemisphere. METHODS: The writing group used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. The panel reviewed the most relevant articles on adults through computerized searches of the medical literature using MEDLINE, EMBASE, and Web of Science through March 2013. The evidence is organized within the context of the American Heart Association framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive American Heart Association internal peer review. RESULTS: Clinical criteria are available for hemispheric (involving the entire middle cerebral artery territory or more) and cerebellar (involving the posterior inferior cerebellar artery or superior cerebellar artery) swelling caused by ischemic infarction. Clinical signs that signify deterioration in swollen supratentorial hemispheric ischemic stroke include new or further impairment of consciousness, cerebral ptosis, and changes in pupillary size. In swollen cerebellar infarction, a decrease in level of consciousness occurs as a result of brainstem compression and therefore may include early loss of corneal reflexes and the development of miosis. Standardized definitions should be established to facilitate multicenter and population-based studies of incidence, prevalence, risk factors, and outcomes. Identification of patients at high risk for brain swelling should include clinical and neuroimaging data. If a full resuscitative status is warranted in a patient with a large territorial stroke, admission to a unit with neurological monitoring capabilities is needed. These patients are best admitted to intensive care or stroke units attended by skilled and experienced physicians such as neurointensivists or vascular neurologists. Complex medical care includes airway management and mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control. In swollen supratentorial hemispheric ischemic stroke, routine intracranial pressure monitoring or cerebrospinal fluid diversion is not indicated, but decompressive craniectomy with dural expansion should be considered in patients who continue to deteriorate neurologically. There is uncertainty about the efficacy of decompressive craniectomy in patients ≥60 years of age. In swollen cerebellar stroke, suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically. Ventriculostomy to relieve obstructive hydrocephalus after a cerebellar infarct should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement. In swollen hemispheric supratentorial infarcts, outcome can be satisfactory, but one should anticipate that one third of patients will be severely disabled and fully dependent on care even after decompressive craniectomy. Surgery after a cerebellar infarct leads to acceptable functional outcome in most patients. CONCLUSIONS: Swollen cerebral and cerebellar infarcts are critical conditions that warrant immediate, specialized neurointensive care and often neurosurgical intervention. Decompressive craniectomy is a necessary option in many patients. Selected patients may benefit greatly from such an approach, and although disabled, they may be functionally independent.

Profile of patients with cerebral venous sinus thrombosis with cerebellar involvement.

BACKGROUND: Cerebral venous thrombosis (CVT) is a rare form stroke with diverse manifestations. There is very little information available regarding profile of patients with cerebellar involvement in CVT. We describe the clinical profile, investigations, and outcome of patients with cerebellar involvement with CVT. METHODS: We prospectively studied 6 (male:female: 5:1, mean age 29.3 ± 10.3 years) patients of CVT with cerebellar involvement (2 isolated cerebellar and 4 associated deep or supratentorial structures) among 330 CVT patients (1.8%) admitted in our stroke unit during a period of 3 years. RESULTS: The presenting features (mean duration 7.0 ± 4.7 days) were headache, vomiting, encephalopathy, ataxia, and papilledema. Initial diagnosis considered were neuroinfection in 2 patients, raised intracranial pressure in 2, subarachnoid hemorrhage in 1, and subacute ataxia in 1 patient. Computed tomography (CT) was diagnostic in 3 of 5 patients, whereas magnetic resonance imaging (MRI) and magnetic resonance venography were diagnostic in all; in addition, MRI was superior in detecting new lesions not visualized on CT, in better delineating hemorrhages and in predicting the age of thrombus. Patients were managed medically with anticoagulation, anti-edema, and anti-epileptics and supportive treatment. Two patients underwent posterior fossa decompression. Four patients made complete recovery at the time of discharge and 2 patients died (1 because of brain stem dysfunction and another because of postoperative pneumonia and septicemia). CONCLUSIONS: Cerebellar involvement in CVT is very rare, and high index of suspicion is required for diagnosis. Imaging with CT and MRI will help in confirming the diagnosis. Conventional anticoagulation is effective in treatment. Mortality was 33%, and there was no disability in survivors.

A treatment option for severe cerebellar hemorrhage with ventricular extension in elderly patients: intraventricular fibrinolysis.

External ventricular drainage (EVD) combined with intraventricular fibrinolysis (IVF) is rarely used in severe spontaneous cerebellar hemorrhage (SCH) with intraventricular hemorrhage (IVH). Recently, the treatment strategy was repeatedly performed in our hospital to elderly patients with severe SCH + IVH. To analyze its clinical value, we compared it to two treatment strategies which now commonly are used for these patients: conservative management (CM) and clot evacuation (CE). In this study, a total of 118 cases were observed, of which 28 cases received CM, 43 cases received EVD + IVF and 47 cases received CE. The Glasgow Coma Scale score, frequency of complication, mortality in one month, modified Rankin Scale (mRS) at six months, and causes of death were analyzed. The outcomes of patients in the CM group were extremely poor compared to patients undergoing surgery (P = 0.034) and the mortality was up to 61.3 % (18/28), which was much higher than those of the two surgical groups (P = 0.026). No significant difference was found in mortality and mRS between the two surgical groups (P > 0.05). Patients in the CE group mostly died of deterioration of comorbidities and postoperative complications, whereas more deaths occurred in the CM group and the EVD + IVF group due to rebleeding, brainstem compression, perilesional edema and tight posterior fossa (χ (2), P = 0.006). It is suggested that EVD + IVF is a treatment option for elderly patients with severe SCH + IVH.

Primary cerebellar haemorrhage: complications, treatment and outcome.

Given its anatomical proximity to the brainstem and the ventricular system, cerebellar haemorrhage may lead to immediate life-threatening complications such as brainstem compression and hydrocephalus, or to herniation through the foramen magnum or the tentorium. This situation mandates fast diagnosis and precise emergency treatment strategies. However, the treatment protocols in current use are based on little evidence and the indication criteria for surgical intervention are unclear. Early suboccipital decompressive surgery may be life-saving, but the potential risk involved is unnecessary if the haemorrhage is benign and can be managed conservatively or with insertion of an external ventricular drain. Deterioration of the patients' state of consciousness has often been used as an indication for surgery, but clinical decline can be a fulminant process leading to death within a short time. Research on cerebellar haemorrhage so far has focused on identifying outcome predictors from which treatment algorithms can be derived. Large randomised controlled trials (RCTs) are lacking. However, RCTs are urgently needed, in order to improve the level of evidence, treatment decisions may be based on. Here, we review the available literature on complications, treatment and outcome of primary cerebellar haemorrhage (PCH). Finally we propose the design of a potential RCT.

Clinical and neuroanatomical predictors of cerebellar mutism syndrome.

Cerebellar mutism syndrome (CMS) is an important medical challenge in the management of pediatric posterior fossa brain tumors, because it occurs in a subset of children following tumor resection. A definitive clinical profile and neuroanatomical substrate associated with CMS remains unclear. We investigated the relationship between presurgical and clinical variables and the incidence of CMS, along with diffusion tensor imaging, to characterize the integrity of cerebello-thalamo-cerebral white matter pathways. Seventeen children with posterior fossa tumors and CMS, 34 children with posterior fossa tumors without CMS, and 28 healthy children were enrolled in this study. Bilateral cerebello-thalamo-cerebral pathways were delineated and segmented into anatomical regions. Mean integrity measures for each region were compared among children with CMS, children without CMS, and healthy children. Left-handedness, medulloblastoma histology, and larger tumor size distinguished between patients with CMS and patients without CMS (P < .04). Right cerebellar white matter within the cerebello-thalamo-cerebral pathway was compromised in children with CMS relative to children without CMS and healthy children (P < .02). We provide a potential schema for CMS risk among children treated for posterior fossa tumors. Left-handed children treated for medulloblastoma may be the most at risk for CMS, and unilateral, localized damage within the cerebello-thalamo-cerebral pathway at the level of the right cerebellum is implicated in the presentation of CMS. This disruption in communication between the right cerebellum and left frontal cortex may contribute to speech-language problems observed in children with CMS. Our findings may be relevant for surgical planning and speech-language therapy to mitigate symptoms of CMS.

Prognostic factors and long-term outcome following surgical treatment of 76 patients with spontaneous cerebellar haematoma.

BACKGROUND: Although large spontaneous cerebellar haematomas are associated with high mortality, surgical treatment may be life-saving. We evaluated the clinical outcome and identified prognostic factors in 76 patients with cerebellar haematoma, all treated with suboccipital decompression, haematoma evacuation and external ventricular drainage. METHODS: Patients receiving surgical and neurocritical care treatment within a 10-year period were included. Level of consciousness during hospitalisation was evaluated using the Glasgow Coma Scale (GCS) score. Outcome was assessed with the modified Rankin Scale (mRS). Predictive prognostic factors were analysed using univariate and multivariate regression analysis. RESULTS: Prior to surgery, the median GCS score was 8.6 (range 3-13). At discharge it had improved to 12.1 (4-15) (p < 0.05). The median long-term follow-up period was 70.5 (22-124) months. At 6 months post-surgery, 19 patients were dead and 28 patients had a good outcome (mRS < 3). In the long term (70.5 months), 31 patients (41.9 %) were dead and the outcome was good in 27 patients (37.8 %). Although approximately 25 % of patients >65 years old had a favourable outcome, age was the strongest negative predictor for a bad outcome at 6 months and long term (p = 0.02 and p = 0.01, respectively). The level of consciousness before surgery did not influence the 6-month or long-term outcome (p = 0.39 and p = 0.65, respectively). CONCLUSIONS: Although mortality was high, significant complications from the treatment were rare and most survivors had a good outcome, reaching functional independence. High age was the strongest prognostic factor for an unfavourable outcome.

Traumatic intra-cerebellar haematoma: study of 17 cases.

PURPOSE: We report on 17 patients with traumatic intra-cerebellar haematomas. METHODS: We retrospectively reviewed patients' clinical and radiological findings, management criteria and outcomes. RESULTS: Ten patients had poor outcomes. Glasgow Coma Scale (GCS) score at admission was significantly higher in the favourable outcome group than in the poor outcome group (p = 0.010). The haematoma volume was significantly smaller in the favourable outcome group than in the poor outcome group (p = 0.025). There were also significant differences between the two groups in terms of types of haematoma location, the status of the brainstem cisterns, the status of the fourth ventricle, and the presence of associated subarachnoid haemorrhage (SAH) (p = 0.035, 0.002, 0.010, 0.003, respectively). CONCLUSIONS: The factors correlated with outcome were GCS score, the status of the brainstem cisterns and the fourth ventricle, the presence of associated SAH, haematoma volume and haematoma location. Further studies are needed to investigate the factors relevant to the management of traumatic intra-cerebellar haematomas.

[Primary intracerebellar hematomas: surgical indications, prognosis]. / Hematoamele intracerebeloase primare: indicatii chirurgicale, prognostic.

Intracerebellar primary hematoma are produced by spontaneous hemorrhages in the cerebellar parenchima and usually present an sudden onset. In the present study we analyzed a serie of 34 cases of primary intracerebellar hematoma, in patients of both genders, between 35 and 80 years old. Taking in account the incidence of symptoms, the clinical picture was dominated by the gait disturbances, headache and consciousness disorders. From the analyzed cases, 50% had had surgical indication and 50% benefits on conservative treatment. Even though the evolution was favorable in the great majority of cases,the mortality in the surgical treated group was lesser (5,88%) comparative to the conservative treated group (17,64%). The main criteria for surgical treatment were represented by GCS (Glasgow Coma Scale) score < or =13 or blood collections exceeding 3 cm in diameter.