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Cerebellar Bleed – Does Neurosurgery Help?

November 6, 2019

Written by Clay Smith

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Surgical decompression of a cerebellar intracerebral hemorrhage (ICH) may improve survival, but it does not seem to improve survival with favorable neurological outcome.

Why does this matter?
Classically, a large cerebellar ICH is considered a neurosurgical emergency. In fact, the AHA guidelines recommend, “surgical hematoma evacuation for cerebellar ICH with diameter greater than 3 cm [or 13.5cm3] to improve outcome.” But is this correct?

It doesn’t take a brain surgeon to…
This was a meta-analysis of 4 observational studies to compare surgical evacuation of cerebellar ICH with non-surgical management. There were a total of 6,580 patients, 578 of which had cerebellar bleeds. Of these, they used propensity score matching to come up with two groups of 152 matched on age, anticoagulation status, and size of bleed. There was no difference in the primary outcome of favorable neurological status at 3 months – mRS 0-3 vs mRS 4-6: 30.9% vs 35.5%, respectively; aOR 0.94 (95%CI 0.81 – 1.09). They found, as secondary outcomes, that overall survival was better at 3 and 12 months. And they found a threshold hematoma size of 12 cm3, below which surgery significantly worsened neurological outcome. Yet, above 15 cm3, surgery improved survival but not neurological outcome. This study is retrospective, and even propensity matching cannot compensate for all potential confounders. We have taught that for large cerebellar bleeds, surgery is the way to go. This study informs us that it may improve survival, but likely not survival without significant disability. And performing surgery on smaller bleeds may actually make matters worse. The only definitive answer to this would be with a RCT.

Association of Surgical Hematoma Evacuation vs Conservative Treatment With Functional Outcome in Patients With Cerebellar Intracerebral Hemorrhage. JAMA. 2019 Oct 8;322(14):1392-1403. doi: 10.1001/jama.2019.13014.

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