Ventriculostomy for hydrocephalus in cerebellar hemorrhage

Ventriculostomy and Risk of Upward Herniation in Patients with Obstructive Hydrocephalus from Posterior Fossa Mass Lesions

BACKGROUND

Patients with posterior fossa lesions causing obstructive hydrocephalus present a unique clinical challenge, as relief of hydrocephalus can improve symptoms, but the perceived risk of upward herniation must also be weighed against the risk of worsening or continued hydrocephalus and its consequences. The aim of our study was to evaluate for clinically relevant upward herniation following external ventricular drainage (EVD) in patients with obstructive hydrocephalus due to posterior fossa lesions.

METHODS

We performed a retrospective review of patients undergoing urgent/emergent EVD placement at our institution between 2007 and 2014, evaluating the radiographic and clinical changes following treatment of obstructive hydrocephalus.

RESULTS

Even prior to EVD placement, radiographic upward herniation was present in 22 of 25 (88%) patients. The average Glasgow Coma Scale of patients before and after EVD placement was 10 and 11, respectively. Radiographic worsening of upward herniation occurred in two patients, and upward herniation in general persisted in 21 patients. Clinical worsening occurred in two patients (8%), though in all others the clinical examination remained stable (44%) or improved (48%) following EVD placement. Of the patients who had a worsening clinical exam, other variables likely also contributed to their decline, and cerebrospinal fluid diversion was likely not the main factor that prompted the clinical change.

CONCLUSIONS

Radiographic presence of upward herniation was often present prior to EVD placement. Clinically relevant upward herniation was rare, with only two patients worsening after the procedure, in the presence of other clinical confounders that likely contributed as well.

Risk Factors for Ventriculoperitoneal Shunt Dependency in Patients with Spontaneous Cerebellar Hemorrhage

BACKGROUND

Hydrocephalus is a common complication after spontaneous cerebellar hemorrhage (CH). This study focused on predicting ventriculoperitorneal (VP) shunt dependency in patients with spontaneous CH.

METHODS

Ninety-nine patients with spontaneous CH were evaluated in this retrospective study. A comparison between patients with and those without VP shunt dependency during hospitalization was made.

RESULTS

VP shunt-dependent hydrocephalus developed in 19.2% of the patients (19 of 99). Comparison of neuroimaging findings on admission between the 2 patient groups identified large hematoma dimension (P < 0.001), large hematoma volume (P = 0.001), fourth ventricular degradation (P < 0.001), development of hydrocephalus (P < 0.001), and obliteration of the basal cisterns (P < 0.001) as significant risk factors for VP shunt-dependent hydrocephalus. Stepwise logistic regression analysis identified hydrocephalus on admission and maximum hematoma diameter on admission as independent risk factors for VP shunt dependency (P = 0.006 and 0.020, respectively). The adjusted risk of VP shunt dependency for patients with hydrocephalus on admission had an odds ratio of 37.04. Furthermore, an increase of 1 mm in the blood clot diameter on admission would increase the VP shunt dependency rate by 11.9%. The cutoff value of blood clot diameter on presentation was 36.15 mm (sensitivity, 84.2%; specificity, 85.0%).

CONCLUSIONS

A patient with hydrocephalus on admission and a hematoma of larger size and dimension at the time of initial imaging is at elevated risk for VP shunt dependency. Repeat neuroimaging studies and careful clinical assessment are mandatory for high-risk patients to determine the presence of post-CH hydrocephalus.

Remote Cerebellar Infarction after Supratentorial Craniotomy and Its Management: Two Case Reports

The cerebellar infarction resulting from supratentorial craniotomy is uncommon event and its management has been controversial. After removal of space occupying lesion on right frontal area, two cases of remote cerebellar infarctions occurred. We reviewed each cases and the techniques to manage such complications are discussed. Early extraventricular catheter insertion and midline suboccipital craniectomy were effectively performed in obtunded patients from cerebellar infarction.

Hydrocephalus in posterior fossa lesions: ventriculostomy and permanent shunt rates by diagnosis

OBJECTIVES

The rate of ventriculostomy for acute hydrocephalus and progression to shunt-dependent chronic hydrocephalus in patients with posterior fossa lesions are not well known.

METHODS

We retrospectively reviewed 104 consecutive cases with posterior fossa lesions on admission to the University of Illinois Hospital from June 2002 to December 2005. We recorded the rate of ventriculostomy and permanent ventricular shunting, which were compared among etiologic groups, using chi-squared and Fisher's exact tests.

RESULTS

Overall, 35 patients had ventriculostomy for acute hydrocephalus and 16 had permanent shunting for shunt-dependent chronic hydrocephalus. Of those with primary posterior fossa intracranial hemorrhage (ICH) (42 cases), 19 (45%) required ventriculostomy, with five (26%) requiring subsequent permanent shunting; 13 patients had hematoma evacuation, with two having permanent shunting. Of those with cerebellar infarction (14 cases), four (29%) required ventriculostomy and one (25%) had a permanent shunt; two had a decompressive craniectomy. Of those with neoplasms (43 cases, 33 surgically resected), ten (23%) required ventriculostomy and nine (21%) required permanent shunting. In addition, two of the three cases with infectious processes required ventriculostomy and one required a permanent shunt. In-hospital mortality was 21% (9/42 cases) for patients with ICH, 14% (2/14 cases) for patients with infarction and 0% for all others.

DISCUSSION

Acute primary posterior fossa hemorrhage has the highest rate of ventriculostomy for acute hydrocephalus and highest inpatient mortality but a surprisingly low rate of permanent shunt-dependency. When hydrocephalus was caused by a neoplasm, there was a higher rate of permanent shunt placement.

Long-Term Outcome after Spontaneous Cerebellar Haemorrhage

We analysed the clinical and radiological findings and the long-term outcome after 49 +/- 34 months in 75 patients (42 men, aged 67 +/- 11 years) with spontaneous cerebellar haemorrhage (SCH). At the follow-up examination, 36 patients had died. Outcome was excellent [Rankin Scale (RS) score 0 + 1] in 22 survivors, 4 patients were moderately (RS score 2 + 3) and 13 patients were severely disabled (RS score 4 + 5). Prognostic factors are haematoma volume, intubation, hydrocephalus and clinical signs of brainstem involvement. Of the 28 surgically treated patients, outcome was favourable (RS score 0 - 2) in 4 patients only, 6 were severely disabled (RS score 3 - 6) and 18 patients had died. We conclude that the long-term outcome after SCH is frequently favourable. Because patients who were surgically treated had less favourable clinical and radiological findings, a good long-term outcome was rarely present in this group.

Paramedian Suboccipital Mini-Craniectomy for Evacuation of Spontaneous Cerebellar Hemorrhage

Patients with spontaneous cerebellar hemorrhage are usually treated by large suboccipital craniectomy for hematoma evacuation or by computed tomography-guided stereotactic aspiration of the hematoma. The present study evaluated the outcome and complications in 25 patients with spontaneous cerebellar hemorrhage treated by paramedian suboccipital mini-craniectomy and 21 patients treated by large suboccipital craniectomy. There were no significant differences between the two groups with respect to age, clinical grade, hematoma volume, hematoma location, hydrocephalus, and mean interval from admission to operation. There was also no significant difference in postoperative outcome between the two groups. However, patients treated by paramedian suboccipital mini-craniectomy were less likely to require blood transfusion, had a shorter operating time, and had less postoperative liquorrhea compared with those undergoing extensive suboccipital craniectomy. Paramedian suboccipital mini-craniectomy is a simple and effective method for hematoma evacuation that causes fewer complications.

Spontaneous cerebellar hemorrhage: clinical remarks on 50 cases

BACKGROUND

Only during the past 10 years have spontaneous cerebellar hemorrhages became a well-defined nosological entity. The surgical indication remains debatable. Our primary objective in this study was to set the criteria for undertaking surgery by determining the critical diameter of the hematoma and considering the patients' neurological status (Glasgow Coma Scale).

METHODS

During the 8-year period 1990 through 1997 a series of 50 consecutive patients with spontaneous cerebellar hemorrhage were admitted to the Emergency Neurosurgery Unit, University of Rome "La Sapienza" (Italy). On admission all patients underwent a standard neurological examination, (Glasgow Coma Scale) and a computed tomographic scan. The diameter and the site of the hematoma, a coexisting tight posterior fossa, and the presence of hypertensive hydrocephalus were the criteria, in association with the patients' neurological status, used as indications for surgery.

RESULTS

Operative mortality was nil; and perioperative mortality eight patients (16%, increasing to 24% including the four patients who were deeply comatose on admission). Most patients who died (seven of eight) had two or more general medical risk factors (arterial hypertension and diabetes mellitus; arterial hypertension and liver disease; or liver disease and hematological disorders).

CONCLUSION

In patients presenting with spontaneous cerebellar hemorrhage the essential criteria indicating surgery are a hematoma 40 mm x 30 mm on CT imaging in the cerebellar hemisphere or 35 mm x 25 mm on CT imaging in the vermis, the presence of a tight posterior fossa (critical size reduced by 10 mm), and a Glasgow Coma Score less than 13.

Predictors of poor outcome in patients with a spontaneous cerebellar hematoma

BACKGROUND AND PURPOSE

The authors studied the clinical and neuroimaging features of cerebellar hematomas to predict poor outcome using comprehensive statistical models.

METHODS

We retrospectively reviewed clinical and neuroimaging features in 94 patients with spontaneous cerebellar hematomas to identify predictive features for a poor neurologic outcome, defined as death or dismissal to long-term care facility. Data were analyzed using chi square and Fisher's exact test with calculation of odd's ratios together with 95% confidence intervals.

RESULTS

Clinical and neuroradiologic predictors for a poor outcome at p < 0.05 were admission systolic blood pressure > 200 mm Hg, hematoma size > 3 cm, visible brain stem distortion, and acute hydrocephalus. Presenting findings predicting subsequent death at p < 0.05 were abnormal corneal and oculocephalic responses, Glasgow coma sum score less than 8, motor response less than localization to pain, acute hydrocephalus and intraventricular hemorrhage.

CONCLUSION

A tree-based analysis model using binary recursive partitioning showed that cornea reflex, hydrocephalus, doll's eyes, age, and size were the most important discriminating factors. Absent corneal reflexes on admission highly predicts poor outcome (86 percent, confidence limits 67-96 percent). When a cornea reflex is present, acute hydrocephalus predicts poor outcome but only when doll's eyes are additionally absent.

Neurosurgical management of cerebellar haematoma and infarct

The clinical features, treatment, and outcome were reviewed for 48 patients with a haematoma and 71 patients with an infarct in the posterior fossa in order to develop a rational plan of management. Clinical features alone were insufficient to make a diagnosis in about half of the series. Patients with a haematoma were referred more quickly to the neurosurgical unit, were more often in coma, and more often had CT evidence of brain stem compression and acute hydrocephalus. Ultimately, 75% of the patients with a haematoma required an operation. By contrast, most patients with an infarct were managed successfully conservatively. Early surgical management in both cerebellar haemorrhage and infarct (either external ventricular drainage or evacuation of the lesion), associated with early presentation and CT signs of brain stem compression and acute hydrocephalus, led to a good outcome in most patients. Of the patients with cerebellar haematoma initially treated by external drainage, over half subsequently required craniectomy and evacuation of the lesion; but, in some cases, this failed to reverse the deterioration. In patients with a cerebellar infarct, external drainage was more often successful. The guidelines, findings, and recommendations for future management of patients with posterior fossa stroke are discussed.

Dr. C. Miller Fisher's description of acute cerebellar hemorrhage

The clinical picture of acute cerebellar hemorrhage and the necessity for rapid recognition and intervention were described by Dr. C. Miller Fisher over 25 years ago. Many of his observations and comments are relevant to current practice.

Management of 50 spontaneous cerebellar haemorrhages. Importance of obstructive hydrocephalus

The records of 50 cerebellar haemorrhages were reviewed retrospectively. In this series the most important factor for clinical development, management and mortality was the presence of obstructive hydrocephalus (p < 0.01). Slowly progressive (type 1) and abruptly developing (type 2) deterioration of consciousness was significantly related to high mortality; this holds also true for the combination of hydrocephalus with an haematoma diameter > 3 cm. Larger haematomas had a higher mortality but this relation, analyzed alone, did not reach statistical significance (p > 0.05). In cases with hydrocephalus mortality could significantly be reduced by surgical evacuation of the haematoma (p < 0.01). The treatment of cerebellar haemorrhages must be directed at resolving obstructive hydrocephalus.

Medical and surgical treatment of intracerebellar haematomas

15 cases of intracerebellar haematomas [11 spontaneous, 2 traumatic and 2 unclear] were presented. Hypertension was thought to be a main risk factor in 91% in 11 of the spontaneous cases. 11 cases were treated medically. They were usually conscious, scoring not less than 13 in GCS with subacute or chronic picture of illness and harbouring small haematomas below 3 cm in diameter situated almost always in the hemisphere and with no signs of ventricular dilation. Mortality in medically treated patients was 9% [1 case]. The remainder were discharged in good state, usually with no or only slight neurological deficit. Complete haematoma absorption took about 14 days. There were no signs of delayed hydrocephalus in subsequent CT scans. When the haematoma was large, more than 3 cm in diameter, located usually in the vermis or in the vermis and cerebellar hemisphere, sometimes with ventricular involvement, the clinical presentation was acute and required CT diagnosis and surgical evacuation without delay due to low and deteriorating conscious level. Postoperative mortality was 25%, but delayed mortality was 100%. Vertebral angiography was performed in all cases of spontaneous haemorrhage and was normal in 54%, revealed atheromatous changes in 36% and the signs of cerebellar haematoma in only 10%. Arteriovenous malformations were excluded from this study. The authors believe, that the benign course of intracerebellar haematomas is more frequent than it was considered previously and needs no surgical treatment in many cases.

Cerebellar hemorrhage: diagnosis and treatment

We have reviewed the records of 22 patients with spontaneous cerebellar hemorrhage. One question that we considered was whether the increased recognition of this disorder, since the introduction of computed tomography (CT) scanning, had brought about a change in the associated signs and symptoms, as compared with previous series. No such change was found. Nine patients died, four after operation (ventricular shunting in one, clot evacuation in one, both procedures in two patients). The five other patients were considered inoperable, because they showed signs of compression of the caudal brainstem. It is improbable that any of these five could have been saved by immediate ventricular drainage, advocated by some as the only treatment. Thirteen patients were treated conservatively and recovered, although four had a hematoma larger than 3 cm. All these patients had a Glasgow coma scale score of 11 points or more. The level of consciousness may be a better guide in management than the size of the clot.

Primary cerebellar hemorrhage. Quadrigeminal cistern obliteration on CT scans as a predictor of outcome

The authors studied a consecutive series of 75 patients with cerebellar hemorrhage diagnosed by computerized tomography (CT) scanning, and assessed the relationship of outcome to the CT appearance of the quadrigeminal cistern, which in some cases was obliterated by rostral displacement of the vermis resulting from the cerebellar mass. Obliteration of the quadrigeminal cisterns was classified on the CT scans into three grades: normal (Grade I), compressed (Grade II), or absent (Grade III). There were 43 patients with Grade I, 16 with Grade II, and 16 with Grade III cisterns. Of the 75 patients, 38 (88.4%) of those with Grade I, 11 (68.8%) of those with Grade II, and none of those with Grade III cisterns returned to their previous activities at 6 months or more after onset. A Grade I cistern predicted a good outcome whether the hematoma was evacuated or not, as long as obstructive hydrocephalus, if present, was relieved early. However, a Grade II cistern was not predictive of a good outcome unless the hematoma was evacuated within 48 hours after onset of the hemorrhage. A Grade III cistern invariably predicted an unfavorable outcome. It is concluded that the CT grade of quadrigeminal cistern obliteration is an accurate indicator of outcome and is highly useful in selecting appropriate treatment for patients with cerebellar hemorrhage.

Cerebellar infarction: natural history, prognosis, and pathology

Using clinical and computed tomography (CT) criteria, an analysis of 2,000 consecutive stroke unit patients from 1977 to 1984 revealed 30 patients with cerebellar infarction. The case fatality rate was 23%, higher than for any other location of brain infarction studied over the same period. Death was most often due to concomitant brainstem infarction. Obstructive hydrocephalus occurred in 4 patients (13%), and in 2 cases diagnosis, facilitated by urgent CT scanning, allowed early surgical intervention that was life saving. Patients who survived the acute phase were followed for an average of 21 months, and over that time 22% sustained further brainstem infarction, representing a 13% stroke rate per year. Over the latter 3 years of the clinical study, an autopsy survey revealed 11 cases of cerebellar infarction that had been clinically unrecognized. None of these died as a direct result of their infarction. Mechanisms of infarction inferred from autopsy included in situ thrombosis, embolism, watershed, and lacunar infarction, with in situ thrombosis being the most common. We conclude that the case fatality rate of cerebellar infarction is greater than of any other form of brain infarction, but it may be reduced by prompt recognition of those patients who will benefit from surgical decompression. In survivors, a high risk of subsequent hindbrain stroke exists. More attention needs to be paid to this entity in terms of early diagnosis and prevention of subsequent stroke.

Clinical and CT scan assessment of benign versus fatal spontaneous cerebellar haematomas

We have studied 15 cases of spontaneous intracerebellar haematomas in 9 males and 6 females. A significant correlation between the clinical presentation and the CT scan features of benign and fatal haemorrhages of the cerebellum is presented. Diagnostic computerized tomographic studies were performed in a mean interval of 31 hours after the initial symptoms. 60% were diagnosed and treated in less than 24 hours; 11 patients had haematomas larger than 3 cm, and 5 (45%) of these cases died with evidence of irreversible brain-stem damage. Twelve (80%) showed compression of the fourth ventricle, 9 (60%) obliteration of the brain-stem cisterns and 8 (53%) ventricular dilatation. 8 cases were treated with surgery; 50% of them showed neurological improvement, including two cases with signs of brain-stem compression. 7 patients who were treated conservatively were followed closely with repeated CT scans, which showed that resolution of the mass effect and isodensity of the haematomas larger than 3 cm (73%), hydrocephalus (45%) and intraventricular haemorrhage (40%). Smaller haematomas without CT scan evidence of obliteration of the brain-stem cisterns or hydrocephalus had a better outcome.

Childhood cerebrovascular diseases not associated with vascular malformations

Of 76 patients in the pediatric age group suffering from cerebrovascular diseases treated in the years 1970-1983, 26 patients (34%) did not harbor intracranial vascular malformations (aneurysms or arteriovenous malformations). Two groups of patients were identified: (a) those suffering from a spontaneous intracranial hemorrhage (16 cases); (b) those suffering from an ischemic stroke (10 cases). Of those with spontaneous intracranial hemorrhage, 10 patients underwent surgery and evacuation of the hematoma. In 2 cases the hematoma was located in the posterior fossa, in 1 case in the upper brain stem, and in 3 cases in the basal ganglia; in the remainder the hematoma was supratentorial. Two patients died soon after the hemorrhage. Eight of the surviving patients completely recovered. In those with ischemic stroke, none suffered from congenital heart disease, a well-known predisposing factor. In this second group 1 patient died and 9 survived. Only one patient showed complete recovery. The data indicate that a hemorrhagic stroke is more common than an ischemic stroke in a child presenting with acute onset of hemiparesis and/or loss of consciousness: thus the value of CT scan as the first diagnostic procedure is clear, owing to the possibility of emergency surgical treatment. In children with ischemic strokes, a complete laboratory/clinical evaluation should be undertaken in order to exclude preexisting heart disease, coagulation disorders or lipoprotein abnormalities, and less common systemic diseases.

Cerebellar strokes: mortality, surgical indications, and results of ventricular drainage

A series of 15 patients with cerebellar haemorrhages and 55 with cerebellar infarcts diagnosed by computerised tomography were studied. 9 haemorrhage patients and 49 infarct patients did not have hydrocephalus; 7 and 44, respectively, survived. All 12 patients with hydrocephalus deteriorated and were subjected to ventricular drainage, 4 of the 6 haemorrhage patients with hydrocephalus survived, 2 in a functional neurological state. All 6 infarct patients with hydrocephalus survived in good condition after ventricular drainage. Hydrocephalus developed in patients with cerebellar haemorrhage more frequently and sooner after the stroke than in patients with cerebellar infarct. Once hydrocephalus had developed, deterioration was more rapid in haemorrhage patients. The most important determining factor in the survival of patients with cerebellar stroke is whether hydrocephalus develops. Consequently, the indication for surgical intervention is the presence of hydrocephalus. Ventricular drainage was effective in the treatment of patients with hydrocephalus accompanying cerebellar stroke, and it is likely that direct surgical attack is unnecessary.