Primary cerebellar haemorrhage: Complications, treatment and outcome

A comparison of the efficacy of computed tomography-guided minimally invasive puncture and drainage and craniotomy for hematoma evacuation in the treatment of cerebellar hemorrhage

OBJECTIVE

This study aimed to compare the efficacy of computed tomography (CT)-guided minimally invasive puncture and drainage (MIPD) and craniotomy for hematoma evacuation in the treatment of cerebellar hemorrhage.

METHODS

This single-center prospective cohort study was conducted from January 2020 to February 2023. During the study period, 40 patients with cerebellar hemorrhage who underwent CT-guided MIPD treatment were enrolled in the CT-guided MIPD (CTGMIPD) group, and 40 patients with the cerebellar hemorrhage who had a propensity score matching that of the CTGMIPD group and who underwent craniotomy for hematoma evacuation were enrolled in the standard craniotomy (SC) group. The primary outcome indicators were the 6-month mortality of the patients and the proportion of survivors with a modified Rankin Scale (mRS) scores of 1 or 2. The secondary outcome indicators were the cerebellar hematoma volume, National Institutes of Health Stroke Scale (NIHSS) score, Glasgow Coma Scale (GCS) score, incidence of postoperative complications, length of hospital stay, and medical costs. In addition, data concerning the patients who died during the study period were further analyzed.

RESULTS

At the 6-month follow-up, there was no significant difference in mortality between the two groups, although the proportion of patients with an mRS scores of 1 or 2 was significantly higher in the CTGMIPD group when compared with the SC group (P = 0.015). No significant differences were observed in the hematoma volume, NIHSS score, and GCS score between the two groups. By contrast, the incidence of postoperative complications, length of hospital stay, and medical costs were significantly lower in the CTGMIPD group than in the SC group (all P < 0.05). When compared with the SC group, the proportion of dead patients with a hematoma volume greater than 30 ml was higher in the CTGMIPD group (P = 0.03). Moreover, after stratification of the patients with a preoperative GCS score ≤8, the CTGMIPD group had a significantly higher mortality rate than the SC group (P = 0.04).

CONCLUSION

The efficacy of CT-guided MIPD in the treatment of cerebellar hemorrhage is close to that of craniotomy for hematoma excavation, although the complication and disability rates of the former are significantly lower than those of the latter. When the preoperative hematoma volume is less than 30 mL or the preoperative GCS score is greater than 8, CT-guided MIPD represents a better choice for the treatment of cerebellar hemorrhage than craniotomy for hematoma evacuation.

Predictors of spontaneous intracerebral hemorrhage mortality: a community-based study in Brno, Czech Republic

BACKGROUND AND OBJECTIVE

Intracerebral hemorrhage (ICH) is a serious medical condition with high mortality. However, factors leading to long-term mortality after ICH are largely unclear. The aim of this community-based study is to assess predictors of long-term mortality after spontaneous ICH.

METHODS

We identified all patients admitted with spontaneous ICH to hospitals with a certified stroke unit in Brno, the second largest city in the Czech Republic (CR), in 2011, the year of the Czech Population and Housing Census. We reviewed their medical records for risk factors, radiographic parameters, and measures of post-stroke neurological deficit [National Institutes of Health Stroke Scale (NIHSS)]. Using the dates of death from the Czech National Mortality Register, we calculated mortality at 30 days, six months, one year, and three years after the ICH. Multivariate analysis with forward stepwise logistic regression was performed to determine independent predictors of mortality (p < 0.05).

RESULTS

In 2011, 1086 patients with stroke were admitted to the four stroke-certified hospitals in Brno, CR. Of these, 134 had spontaneous ICH, with complete data available in 93 of them entering the final analysis. The mortality at 30 days, 6 months, 1 year, and 3 years post-ICH was 34%, 47%, 51%, and 63%, respectively. The mortality was highest in the first few days post-event, with 50% of patients dying in 255 days and average survival being 884 ± 90 days. Both NIHSS and modified ICH (MICH) score showed to be strong and reliable predictors of short- as well as long-term mortality; the risk of death post-ICH increased with older age and size of ICH. Other risk factors contributing to higher, primarily shorter-term mortality included history of cardiac failure, myocardial infarction, or atrial fibrillation.

CONCLUSIONS

In our community-based study, we found that severity of neurological deficit at admission (NIHSS), combined with age and size of ICH, well predicted short- as well as long-term mortality after spontaneous ICH. A history of cardiac failure, myocardial infarction, or atrial fibrillation at presentation were also predictors of mortality, underscoring the need for optimal cardiac management in patients with ICH.

Surgery for spontaneous supratentorial intracerebral haemorrhage

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the efficacy and safety of surgery plus standard medical management, compared to standard medical management alone, in people with spontaneous supratentorial ICH, and to assess whether the effect of surgery differs according to the surgical technique.

Computed Tomography Angiography Spot Sign, Hematoma Expansion, and Functional Outcome in Spontaneous Cerebellar Intracerebral Hemorrhage

[Figure: see text].

Secondary Hematoma Evacuation and Outcome After Initial Conservative Approach for Patients with Cerebellar Hematoma Larger than 3 cm

Background

In patients with spontaneous cerebellar intracerebral hemorrhage (ICH) guidelines advocate evacuation when the hematoma diameter is > 3 cm. We studied outcome in patients with cerebellar ICH > 3 cm who did not undergo immediate hematoma evacuation.

Methods

We included consecutive patients with cerebellar ICH > 3 cm at two academic hospitals between 2008 and 2017. Patients who died < 24 h (h) were excluded because of probable confounding by indication. We determined patient characteristics, hematoma volumes, EVD placement, secondary hematoma evacuation, in-hospital and 3-month case-fatality, and functional outcome.

Results

Of 130 patients with cerebellar ICH, 98 (77%) had a hematoma > 3 cm of whom 22 (23%) died < 24 h and 28 (29%) underwent hematoma evacuation < 24 h. Thus, 48 patients were initially treated conservatively (mean age 70 ± 13, 24 (50%) female). Of these 48 patients, 7 (15%) underwent secondary hematoma evacuation > 24 h, of whom 1 (14%) had received an EVD < 24 h. Five others also received an EVD < 24 h without subsequent hematoma evacuation. Of the 41 patients without secondary hematoma evacuation, 11 (28%) died and 20 (51%) had a favorable outcome (mRS of 0–3) at 3 months. The 7 patients who underwent secondary hematoma evacuation had a decrease in GCS score of at least two points prior to surgery; two (29%) had deceased at 3 months; and 5 (71%) had a good functional outcome (mRS 0–3).

Conclusions

While cerebellar ICH > 3 cm is often considered an indication for immediate hematoma evacuation, there may be a subgroup of patients in whom surgery can be safely deferred. Further data are needed to assess the optimal timing and indications of surgical treatment in these patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12028-021-01203-6.

Surgery for spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage is a devastating disease, accounting for 10 to 15% of all types of stroke; however, it is associated with disproportionally higher rates of mortality and disability. Despite significant progress in the acute management of these patients, the ideal surgical management is still to be determined. Surgical hematoma drainage has many theoretical benefits, such as the prevention of mass effect and cerebral herniation, reduction in intracranial pressure, and the decrease of excitotoxicity and neurotoxicity of blood products.

Several surgical techniques have been considered, such as open craniotomy, decompressive craniectomy, neuroendoscopy, and minimally invasive catheter evacuation followed by thrombolysis. Open craniotomy is the most studied approach in this clinical scenario, the first randomized controlled trial dating from the early 1960s. Since then, a large number of studies have been published, which included two large, well-designed, well-powered, multicenter, multinational, randomized clinical trials. These studies, The International Surgical Trial in Intracerebral Hemorrhage (STICH), and the STICH II have shown no clinical benefit for early surgical evacuation of intraparenchymal hematoma in patients with spontaneous supratentorial hemorrhage when compared with best medical management plus delayed surgery if necessary. However, the results of STICH trials may not be generalizable, because of the high rates of patients’ crossover from medical management to the surgical group. Without these high crossover percentages, the rates of unfavorable outcome and death with conservative management would have been higher. Additionally, comatose patients and patients at risk of cerebral herniation were not included. In these cases, surgery may be lifesaving, which prevented those patients of being enrolled in such trials. This article reviews the clinical evidence of surgical hematoma evacuation, and its role to decrease mortality and improve long-term functional outcome after spontaneous intracerebral hemorrhage.

Haematoma evacuation in cerebellar intracerebral haemorrhage: systematic review

BACKGROUND

Guidelines regarding recommendations for surgical treatment of spontaneous cerebellar intracerebral haemorrhage (ICH) differ. We aimed to systematically review the literature to assess treatment strategies and outcomes.

METHODS

We searched PubMed and Embase between 1970 and 2019 for randomised or otherwise controlled studies and observational cohort studies. We included studies according to predefined selection criteria and assessed their quality according to the Newcastle-Ottawa Scale (NOS) and risk of bias according to a predefined scale. We assessed case fatality and functional outcome in patients treated conservatively or with haematoma evacuation. Favourable functional outcome was defined as a modified Rankin Scale score of 0-2 or a Glasgow Outcome Scale score of 4-5.

RESULTS

We included 41 observational cohort studies describing 2062 patients (40% female) with spontaneous cerebellar ICH. A total of 1171 patients (57%) underwent haematoma evacuation. Ten studies described a cohort of surgically treated patients (n=533) and 31 cohorts with both surgically and conservatively treated patients (n=638 and n=891, respectively). There were no randomised clinical trials nor studies comparing outcome between the groups after adjustment for differences in baseline characteristics. The median NOS score (IQR) was 5 (4-6) out of 8 points and the bias score was 2 (1-3) out of 8, indicative of high risk of bias. Case fatality at discharge was 21% (95% CI 17% to 25%) after conservative treatment and 24% (95% CI 19% to 29%) after haematoma evacuation. At ≥6 months after conservative treatment, case fatality was 30% (95% CI 25% to 30%) and favourable functional outcome was 45% (95% CI 40% to 50%) and after haematoma evacuation, case fatality was 34% (95% CI 30% to 38%) and 42% (95% CI 37% to 47%).

CONCLUSIONS

Controlled studies on the effect of neurosurgical treatment in patients with spontaneous cerebellar ICH are lacking, and the risk of bias in published series is high. Due to substantial differences in patient characteristics between conservatively and surgically treated patients, and high variability in treatment indications, a meaningful comparison in outcomes could not be made. There is no good published evidence to support treatment recommendations and controlled, preferably randomised studies are warranted in order to formulate evidence-based treatment guidelines for patients with cerebellar ICH.

Posterior Fossa Surgery for Stroke: Differences in Outcomes Between Cerebellar Hemorrhage and Infarcts

BACKGROUND

Posterior fossa surgery is the established treatment for large cerebellar strokes with brainstem compression. Despite this, there is a paucity of data for long-term outcomes.

METHODS

A retrospective analysis of patients who underwent posterior fossa surgery for cerebellar hemorrhages and infarcts was performed to compare their difference in 6-month outcomes and to identify factors that affect outcomes. Patients were dichotomized into groups with good outcomes (modified Rankin scale [mRS] score 0-3) or poor outcomes (mRS score 4-6). Sex, age, preoperative Glasgow Coma Scale score, Charleston comorbidity index, time to surgery, intraventricular hemorrhage, surgical complications, length of intensive care unit and hospital stay, shunt dependence, and tracheostomy rates were analyzed.

RESULTS

In total, 126 patients were recruited: 76 in hemorrhage group and 50 in infarct group. There was a greater mortality in the hemorrhage group (P = 0.0730). At 6 months, more patients in the hemorrhage group had poor outcomes (P = 0.0074, odds ratio 3.04) and greater mortality (P = 0.0730, odds ratio 2.20). More patients in the hemorrhage group required a tracheostomy (P = 0.0245). Factors predictive of poor outcome include older age (P = 0.0108), Glasgow Coma Scale score ≤8 (P = 0.0011), and tracheostomy (P = 0.0269). A total of 69.2% of patients had improvements in mRS scores at 6 months. Shorter length of stay (P = 0.0003) and discharge to a rehabilitation hospital (P = 0.0001) were predictive of functional improvement.

CONCLUSIONS

Patients who underwent posterior fossa surgery for cerebellar hemorrhage had worse outcomes compared with patients with cerebellar infarcts and were more likely to require a tracheostomy. Rehabilitation helped to improved outcomes.

Predictive factors of neurologic deterioration in patients with spontaneous cerebellar hemorrhage: a retrospective analysis

Background

Cerebellar hemorrhage is a potentially life-threatening condition and neurologic deterioration during hospitalization could lead to severe disability and poor outcome. Finds out the factors influencing neurologic deterioration during hospitalization is essential for clinical decision-making.

Methods

One hundred fifty-five consecutive patients who suffered a first spontaneous cerebellar hemorrhage (SCH) were evaluated in this 10-year retrospective study. This study aimed to identify potential clinical, radiological and clinical scales risk factors for neurologic deterioration during hospitalization and outcome at discharge.

Results

Neurologic deterioration during hospitalization developed in 17.4% (27/155) of the patient cohort. Obliteration of basal cistern (p≦0.001) and hydrocephalus (p≦0.001) on initial brain computed tomography (CT), median Glasgow Coma Scale (GCS) score at presentation (p≦0.001) and median intracerebral hemorrhage (ICH) score (P≦0.001) on admission were significant factors associated with neurologic deterioration. Stepwise logistic regression analysis showed that patients with obliteration of basal cistern on initial brain CT scan had an odds ratio (OR) of 9.17 (p = 0.002; 95% confidence interval (CI): 0.026 to 0.455) adjusted risk of neurologic deterioration compared with those without obliteration of basal cistern. An increase of 1 point in the ICH score on admission would increase the neurologic deterioration rate by 83.2% (p = 0.010; 95% CI: 1.153 to 2.912). The ROC curves showed that the AUC for ICH score on presentation was 0.719 (p = 0.000; 95% CI: 0.613–0.826) and the cutoff value was 2.5 (sensitivity 80.5% and specificity 73.7%).

Conclusion

Patients had obliteration of basal cistern on initial brain CT and ICH score greater or equal to 3 at admission implies a greater danger of neurologic deterioration during hospitalization. Cautious clinical assessments and repeated brain images study are mandatory for those high-risk patients to prevent neurologic deterioration during hospitalization.

The profile of blunt traumatic infratentorial cranial bleed types

Infratentorial traumatic intracranial bleeds (ICBs) are rare and the distribution of subtypes is unknown. To characterize this distribution the National Trauma Data Bank (NTDB) 2014 was queried for adults with single type infratentorial ICB, n = 1,821: subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), epidural hemorrhage (EDH), and intraparenchymal hemorrhage (IPH). Comparisons were made between the groups with statistical significance determined using chi squared and t-tests. SDH occurred in 29% of patients, mostly in elderly on anti-coagulants (13%) after a fall (77%), 42% of them underwent craniotomy, their mortality was the lowest (4%). SAH was the most common (56%) occurring mostly from traffic related injuries (27%). Furthermore, 9% of them had a severe head injury Glasgow Coma Scale ≤8 (GCS), but had the lowest Injury Severity Score (ISS, median 8) as well as a short hospital length of stay, 5.1 ± 6.2 days. These patients were most likely to be discharged to home (64%). They had the lowest mortality (4%). EDH was the least common ICB (5%), occurred in younger patients (median age 49 years), and it had the highest percentage of associated injuries (13%). EDH patients presented with the poorest neurological status (26% GCS ≤8, ISS median 25) and were operated on more than any other ICB type (55%). EDH was the highest mortality (9%) ICB type and had a low discharge to home rate (58%). IPH was uncommon (10%). Infratentorial bleeds types have different clinical courses, and outcomes. Understanding these differences can be useful in managing these patients.

Endoscopic surgery via a combined frontal and suboccipital approach for cerebellar hemorrhage

Background

Spontaneous cerebellar hemorrhages (CHs), which frequently require surgical intervention, are life-threatening and can be complicated by intraventricular hemorrhages (IVHs) and obstructive hydrocephalus. Commonly, endoscopic surgery is performed to remove CHs via a suboccipital approach (SA) alone. At our institution, when patients exhibited supratentorial IVH-associated hydrocephalus, we used a combined frontal and suboccipital approach (CA) to evacuate both CHs and supratentorial IVHs. The present study retrospectively evaluated the effectiveness and safety of this CA, as no prior studies examining this approach currently exist.

Methods

Twenty-six patients with spontaneous CH were surgically treated at our hospital from April 2009 to March 2016. Twenty-two patients who could independently perform activities of daily living before the onset underwent endoscopic surgery to evacuate the CHs; among these, 13 patients underwent the SA alone, while nine underwent the CA. We assessed and compared the patients' baseline characteristics, surgical results, and prognosis at 1 month after the intervention between the SA and CA groups.

Results

Patients who underwent the CA had significantly poorer consciousness before the surgery owing to IVH extension and obstructive hydrocephalus. However, the surgical results and prognosis at 1 month were not significantly different between the two approaches. The CH-associated IVHs were successfully removed with the CA and resulted in shorter external ventricular drainage (EVD) placement durations.

Conclusion

Endoscopic surgery performed via the CA appeared to neutralize the deteriorating effects of CH-associated IVHs. Surgical strategies employing the CA may have the potential to improve the prognosis of patients with CH.

The neuropathology of the adult cerebellum

This chapter summarizes the neuropathologic features of nonneoplastic disorders of the adult cerebellum. Gait ataxia and extremity dysmetria are clinical manifestations of diseases that interrupt the complex cerebellar circuitry between the neurons of the cerebellar cortex, the cerebellar nuclei (especially the dentate nuclei), and the inferior olivary nuclei. The cerebellum is a prominent target of several sporadic and hereditary neurodegenerative diseases, including multiple system atrophy, spinocerebellar ataxia, and Friedreich ataxia. Purkinje cells display selective vulnerability to hypoxia but a surprising resistance to hypoglycemia. A classic toxin that damages the cerebellar cortex is methylmercury, but the most common injurious agent to Purkinje cells is ethanol. Many drugs cause ataxia, but doubts continue about phenytoin. Ischemic lesions of the cerebellum due to arterial thrombosis or embolism cause a spectrum of symptoms and signs, depending on the territory involved. Large hemorrhages have an unfavorable prognosis because they displace critical brainstem structures or penetrate into the fourth ventricle. Fungal infections and toxoplasmosis of the cerebellum, and cerebellar progressive multifocal leukoencephalopathy, have become rarer because of improved control of the acquired immunodeficiency syndrome. Ataxia is a prominent feature of prion disease. Adult-onset Niemann-Pick type C1 disease and Kufs disease may have a predominantly ataxic clinical phenotype. The adult cerebellum is also vulnerable to several leukodystrophies. A rare but widely recognized complication of cancer is paraneoplastic cerebellar degeneration.

Treatment of intracerebellar haemorrhage: Poor outcome and high long-term mortality

Background:

Intracerebellar haemorrhage constitutes around 10% of all spontaneous, non-aneurysmal intracerebral haemorrhages (ICHs) and often carries a grim prognosis. In symptomatic patients, surgical evacuation is usually regarded the standard treatment. Our objective was to compare the in-hospital mortality and functional outcome at hospital discharge in either medically or surgically treated patients, and the impact of either treatment on long-term mortality after a cerebellar ICH.

Methods:

An observational, retrospective, single-centre consecutive series of 114 patients with cerebellar ICH. We assessed the effect of different demographic factors on functional outcome and in-hospital mortality using logistic regression. We also divided the patients in medical and surgical treatment groups based on how they had been treated and compared the clinical and radiological parameters, in-hospital, and long-term mortality in the different groups.

Results:

In our series, 38 patients (33.3%) underwent haematoma evacuation and 76 (66.7%) received medical treatment. Glasgow coma scale <8, blocked quadrigeminal cistern, and severe hydrocephalus were associated with in-hospital death or poor functional outcome at discharge (modified Rankin scale 4-6). Surgically treated patients were younger, had larger haematomas both in volume and diameter, were in a worse clinical condition, and suffered more from hydrocephalus and brainstem compression. There were no statistically significant differences in in-hospital or long-term mortality. However, the surgically treated patients remained in a poor clinical condition.

Conclusions:

Surgical treatment of cerebellar ICH can be life-saving but often leads to a poor functional outcome. New studies are needed on long-term functional outcome after a cerebellar ICH.

Acute Posterior Cranial Fossa Hemorrhage-Is Surgical Decompression Better than Expectant Medical Management?

Background

To compare the in-hospital mortality and institutional morbidity from medical therapy (MT), external ventricular drainage (EVD) and suboccipital decompressive craniectomy (SDC) following an acute hemorrhagic posterior cranial fossa stroke (PCFH) in patients admitted to the neurosciences critical care unit (NCCU). Retrospective observational single-center cohort study in a tertiary care center. All consecutive patients (n = 104) admitted with PCFH from January 1st 2005–December 31st 2011 were included in the study.

Methods

All patients with a PCFH were identified and confirmed by reviewing computed tomography of the brain reported by a specialist neuroradiologist. Management decisions (MT, EVD, and SDC) were identified from operative notes and electronic patient records.

Results

Following a PCFH, 47.8 % (n = 11) patients died after EVD placement without decompression, 45.7 % (n = 16) died following MT alone, and 17.4 % (n = 8) died following SDC. SDC was associated with lower mortality compared to MT with or without EVD (χ² test p = 0.006, p = 0.008). Age, ICNARC score, brain stem involvement, and hematoma volume did not differ significantly between the groups. There was a statistically significant increase in hydrocephalus and intraventricular bleeds in patients treated with EVD placement and SDC (χ² test p = 0.02). Median admission Glasgow Coma Scale scores for the MT only, MT with EVD, and SDC groups were 8, 6, and 7, respectively (ranges 3–15, 3–11 and 3–13) and did not differ significantly (Friedman test: p = 0.89). SDC resulted in a longer NCCU stay (mean of 17.4 days, standard deviation = 15.4, p < 0.001) and increased incidence of tracheostomy (50 vs. 17.2 %, p = 0.0004) compared to MT with or without EVD.

Conclusions

SDC following PCFH was associated with a reduction in mortality compared to expectant MT with or without EVD insertion. A high-quality multicenter randomized control trial is required to evaluate the superiority of SDC for PCFH.

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.

Feasibility and utility of an integrated medical imaging and informatics smartphone system for management of acute stroke

Background

Rapid dissemination and coordination of clinical and imaging data among multidisciplinary team members are essential for optimal acute stroke care.

Aim

To characterize the feasibility and utility of the Synapse Emergency Room mobile (Synapse ERm) informatics system.

Methods

We implemented the Synapse ERm system for integration of clinical data, computerized tomography, magnetic resonance, and catheter angiographic imaging, and real-time stroke team communications, in consecutive acute neurovascular patients at a Comprehensive Stroke Center.

Results

From May 2014 to October 2014, the Synapse ERm application was used by 33 stroke team members in 84 Code Stroke alerts. Patient age was 69.6 (±17.1), with 41.5% female. Final diagnosis was: ischemic stroke 64.6%, transient ischemic attack 7.3%, intracerebral hemorrhage 6.1%, and cerebrovascular-mimic 22.0%. Each patient Synapse ERm record was viewed by a median of 10 (interquartile range 6–18) times by a median of 3 (interquartile range 2–4) team members. The most used feature was computerized tomography, magnetic resonance, and catheter angiography image display. In-app tweet team, communications were sent by median 1 (interquartile range 0–1, range 0–13) users per case and viewed by median 1 (interquartile range 0–3, range 0–44) team members. Use of the system was associated with rapid treatment times, faster than national guidelines, including median door-to-needle 51.0 min (interquartile range 40.5–69.5) and median door-to-groin 94.5 min (interquartile range 85.5–121.3). In user surveys, the mobile information platform was judged easy to employ in 91% (95% confidence interval 65%–99%) of uses and of added help in stroke management in 50% (95% confidence interval 22%–78%).

Conclusion

The Synapse ERm mobile platform for stroke team distribution and integration of clinical and imaging data was feasible to implement, showed high ease of use, and moderate perceived added utility in therapeutic management.

Effect of Admission Hyperglycemia on 6-Month Functional Outcome in Patients with Spontaneous Cerebellar Hemorrhage

Background

Cerebellar hemorrhage (CH) has a quite different treatment strategy and prognostic factors compared with supratentorial intracerebral hemorrhage (ICH). The prognostic role of hyperglycemia has been discussed mainly in cases of supratentorial hemorrhage; it remains to be elucidated following CH. We aimed to determine the association of hyperglycemia on admission with 6-month functional outcome in CH patients.

Material/Methods

We retrospectively analyzed 77 patients with acute CH between September 2010 and April 2015 in West China Hospital. Blood glucose level was measured when the patients were admitted. Primary outcome was 6-month functional outcome, which could comprehensively reflect the patient’s recovery of physical and social ability after stroke and was assessed by the modified Rankin scale (mRS). Association of hyperglycemia with functional outcome was identified in logistic regression models.

Results

There were 50 (64.9%) patients with poor functional outcomes. Patients with poor outcome were much older (P<0.001) and had a significantly higher glucose level on admission (P<0.001), a lower Glasgow Coma Scale score (P<0.001), a larger hematoma (P=0.003), and a higher incidence of intraventricular extension (P=0.002), brainstem compression (P=0.013), and hydrocephalus (P=0.023). Multivariate analysis showed that hyperglycemia (OR 1.50, 95% CI 1.07–2.08, P=0.017 when glucose level was analyzed as a continuous variable; OR 7.46, 95% CI 1.41–39.51, P=0.018 when glucose level was dichotomized by the critical threshold of 6.78 mmol/L) emerged as an independent predictor for adverse functional outcome at 6 months.

Conclusions

To the best of our knowledge, this is the first study focusing on the relationship between hyperglycemia and long-term functional outcome after CH. The study combined with previous pertinent reports definitely indicates the poor effect of hyperglycemia on both supra- and infratentorial ICH independent of hemorrhage site. Therefore, further controlled trials are urgently needed to evaluate the benefits of glucose-lowing treatment.

Does suboccipital decompression and evacuation of intraparenchymal hematoma improve neurological outcome in patients with spontaneous cerebellar hemorrhage?

OBJECTIVE

Spontaneous cerebellar hemorrhages (SCH) can lead to life-threatening complications with high mortality rates of 20-50%. Although complications of SCH can be prevented by surgical therapy, there is a lack of consensus concerning the optimal surgical technique for evacuating SCH.

METHODS

In this retrospective study 85 patients with SCH were divided into four treatment groups: (1) Decompression and Hematoma Evacuation via suboccipital craniectomy and removal of the posterior arch of C1 (DHE). (2) Hematoma Evacuation Only via craniotomy (HEO). (3) External Ventricular Drainage (EVD). (4) Conservative treatment (C). To ascertain the level of consciousness, Glasgow Coma Scale (GCS) was calculated. To evaluate the clinical and neurological outcome, modified Rankin Score, Glasgow Outcome Scale and mortality rate were recorded after 6months.

RESULTS

The mean volume of hematoma was significant larger in the DHE- and HEO-group compared to the EVD- and C-group before treatment. DHE and HEO could significantly reduce the volume comparing pre- and postoperative measurements. Larger preoperative volume was a strong predictor of worse neurological outcome and high mortality. Overall mortality was 25.9%. After subdivision into the treatment groups, a comparison of the DHE- and HEO-groups showed a trend towards lower mortality and better neurological outcome in the DHE-group. Patients with the worst preoperative GCS scores profited significantly from DHE with respect to regaining consciousness.

CONCLUSIONS

Patients with SCH should receive surgical therapy when hemorrhages are space-occupying and when the patient's neurological condition deteriorates. With regards to surgical technique, and limited by the retrospective design of the study, our results indicate that patients might benefit most from DHE.

Neurogenic pulmonary oedema complicating traumatic posterior fossa extradural haematoma: Case report and review

INTRODUCTION

Pulmonary oedema is accumulation of fluid in the lung air spaces and interstitia. Neurogenic pulmonary oedema (NPE) is a potentially life-threatening condition which has been noted in head injury, subarachnoid haemorrhage (SAH), intracerebral haemorrhage (ICH) and others. Timely management is crucial to achieve good outcome; however, no specific guidelines have been defined.

METHODS

A 33-year female involved in a motor vehicular accident had a GCS of 14/15 and CT scan showed a moderate-sized unilateral posterior fossa extradural haematoma (PFEDH). She had sudden deterioration in her haemodynamic status with drop in sensorium 2 hours after admission. There was a copious amount of frothy secretions noted on intubation and she was diagnosed as having NPE.

RESULTS

Sub-occiptial craneictomy (SOC) with haematoma evacuation was performed and was managed with PEEP mechanical ventilation post-operatively. Excellent outcome was obtained and was discharged with a GOS of 5.

CONCLUSIONS

NPE is a poorly understood and uncommon complication of acute CNS injury and should be considered in any patient with acute respiratory distress in the setting of CNS injury. Reduction in ICP and supportive mechanical ventilation form the mainstay of management. Diagnosis of NPE remains challenging and more reliable diagnostic criteria need to be defined to identify such cases with greater frequency.

Neurogenic pulmonary edema caused by spontaneous cerebellar hemorrhage: A fatal case report

Background:

Neurogenic pulmonary edema (NPE) is a clinical syndrome characterized by an acute increase of pulmonary interstitial and alveolar fluid. It could result from a significant central nervous system (CNS) insult such as intracranial hemorrhage. However, NPE as a major presenting manifestation of cerebellar hemorrhage was seldom reported.

Case Description:

We introduce a rare case of a 34-year-old woman suffering from a fulminant NPE in parallel with a spontaneous cerebellar hemorrhage. Although appropriate supportive measures were taken in the neuroscience care unit, the patient failed to survive hypoxemia within 28 h after hospital admission.

Conclusion:

Pathological lesions of the cerebellum may initiate a cascade of reactions including massive sympathetic discharge and catecholamine storm, leading to a dysfunction of both cardiovascular and respiratory systems. By far, no effective therapeutic strategies have been utilized to treat such a situation. Our present report would shed light on the underlying mechanism of NPE.