Indications for Surgery in Cerebellar Hemorrhage
Patients with cerebellar hemorrhage >3 cm in diameter, or those with brainstem compression or hydrocephalus, should undergo urgent surgical evacuation via suboccipital craniectomy regardless of initial clinical status. 1
Primary Surgical Indications (Class I Recommendation)
The decision to operate on cerebellar hemorrhage is more straightforward than supratentorial bleeds due to the unique anatomy of the posterior fossa:
Absolute Indications for Immediate Surgery
Hematoma diameter >3 cm on CT scan - These patients consistently show poor outcomes with medical management alone and require urgent evacuation 1
Brainstem compression - Any radiographic evidence of brainstem distortion mandates immediate surgical decompression 1
Obstructive hydrocephalus - Fourth ventricular compression or complete effacement (Grade III compression) requires urgent clot evacuation 1, 2
Neurological deterioration - Progressive decline in consciousness, new brainstem signs (pupillary abnormalities, loss of oculocephalic reflexes), or worsening GCS score ≥2 points necessitates immediate surgery 3, 2
Critical Pitfall to Avoid
Ventricular catheter placement alone is insufficient and potentially harmful in cerebellar hemorrhage with brainstem compression or compressed cisterns. 1 The hematoma itself must be evacuated - attempting to manage intracranial pressure through external ventricular drainage without removing the clot leads to worse outcomes 1.
Conservative Management Criteria
Small cerebellar hemorrhages (<3 cm) without brainstem compression or hydrocephalus can be managed medically with close monitoring 1, 4. However, these patients require:
ICU-level monitoring for at least 5 days - Deterioration can occur late due to progressive edema even in initially stable patients 3
Serial neurological assessments - Hourly evaluation of consciousness level and brainstem signs 3
Repeat imaging if clinical change occurs - Any decline in GCS score or new brainstem signs warrants immediate CT and surgical consultation 2
Grading System for Decision-Making
The degree of fourth ventricular compression provides an objective framework 2:
Grade I (normal fourth ventricle): Medical management appropriate if GCS >13 and stable 2
Grade II (compressed fourth ventricle): Surgery indicated if GCS deteriorates or hydrocephalus develops 2
Grade III (completely effaced fourth ventricle): Immediate surgical evacuation required, especially if patient conscious at presentation - 43% of conscious patients with Grade III compression deteriorate acutely 2
Age Considerations
While the guidelines emphasize surgical intervention for large cerebellar hemorrhages, clinical practice patterns show that surgeons are more likely to operate on patients <70 years old with large hematomas, often withholding surgery from older patients despite similar radiographic findings. 5 However, the formal guidelines do not support age-based exclusion criteria for surgery when standard indications are met 1.
Surgical Technique
Suboccipital craniectomy with dural expansion remains the standard approach 3, though emerging evidence suggests neuroendoscopic evacuation may offer comparable outcomes with shorter operative time and less blood loss 6. The key surgical goal is complete decompression of the posterior fossa and resolution of mass effect on the brainstem 6, 2.
Timing of Intervention
Surgery should be performed as soon as possible once indications are met - the narrow confines of the posterior fossa allow rapid deterioration from obstructive hydrocephalus or brainstem compression 1. Conscious patients with Grade III fourth ventricular compression should undergo urgent evacuation before deterioration occurs 2.
Poor Prognostic Indicators
Patients presenting with GCS ≤8 (comatose) at the time of treatment have universally poor outcomes regardless of surgical intervention 1, 2. None of the patients with Grade III compression and GCS <8 achieved good functional outcomes in prospective series 2. This information is critical for informed consent and goals-of-care discussions with families.
Contraindication to Surgery
Brainstem hemorrhages should not be evacuated - in contrast to cerebellar hemorrhage, surgical evacuation of pontine or other brainstem hemorrhages may be harmful 1, 7.