Predictors of poor outcome in patients with a spontaneous cerebellar hematoma

Risk factors of prognosis for spontaneous cerebellar hemorrhage: a systematic review and meta-analysis

BACKGROUND

The most deadly type of spontaneous intracerebral hemorrhage is spontaneous cerebellar hemorrhage (SCH). The purpose of this meta-analysis was to investigate risk factors for prognosis in SCH patients to provide a basis for taking preventive and therapeutic measures.

METHODS

Seven electronic databases were searched from inception to May 2023 for randomized controlled trial, cohort study, case control study and cross-sectional study on prognosis of spontaneous cerebellar hemorrhage. The quality of the selected studies were assessed by the American Agency for Healthcare Research and Quality (AHRQ). To assess the impact of the included risk factors on the prognosis of spontaneous cerebellar hemorrhage, combined odds ratios (ORs) with matching 95% confidence intervals (CIs) were combined.

RESULTS

Eight studies were included, including 539 participants. And a total of 31 potentially associated risk factors were identified. Ultimately, 6 risk factors were included in the meta-analysis after assessing. The factors supported by moderate evidence include the hydrocephalus (OR = 4.3, 95% CI: 2.33 to 7.91) and drug-induced coagulopathy (OR = 2.74, 95% CI: 1.23 to 6.09). The factors supported by limited evidence include the intraventricular bleeding(OR = 1.86, 95% CI: 1.13 to 3.07) and hematoma size>3 cm(OR = 3.18, 95% CI: 1.87 to 5.39). Meta-analysis revealed no association between hypertension, diabetes mellitus and SCH prognosis.

CONCLUSION

The current meta-analysis revealed obvious risk factors for prognosis in spontaneous cerebellar hemorrhage patients, including hydrocephalus, drug-induced coagulopathy, intraventricular bleeding and hematoma size>3 cm.

Predictors of Outcomes in Cerebellar Stroke: A Retrospective Cohort Study From the National Inpatient Sample Data

Cerebellar strokes have high morbidity and mortality due to bleeding or edema, leading to increased pressure in the posterior fossa. This retrospective cohort study analyzed three outcomes following a cerebellar stroke: in-hospital mortality, length of hospital stay, and total hospitalization costs. It uses data from the National Inpatient Sample (NIS) and aims to identify the predictors of outcomes in cerebellar stroke patients, including 464,324 patients, 18 years of age and older, hospitalized between 2010 and 2015 in US hospitals with cerebellar strokes. In our study, for every decade age increased beyond 59 years, there was a significant increase in mortality; those aged 80+ years had 5.65 odds of mortality (95% CI: 5.32-6.00; P < 0.0001). Significant differences in patient characteristics were observed between patients who survived to discharge and those who did not, including older age (77.4 vs. 70.3 years; P < 0.0001), female sex (58% vs. 52%; P < 0.0001), and being transferred from another healthcare facility (17% vs. 10%; P < 0.0001). Patients admitted directly rather than through the emergency department were more likely to die (29% vs. 16%; P < 0.0001). The mortality rate was lower for blacks (OR: 0.75; P < 0.0001), Hispanics (OR: 0.91; P = 0.005), and Asians (OR: 0.89; P = 0.03), as compared to the white population, for females in comparison to males, and geographically, in all other areas (Midwest, South, and West) in contrast to the Northeast. Cerebellar stroke incidence and high mortality were seen in the traditional stroke belt. Mortality is also affected by the severity of the disease and increases with the Charlson Comorbidity Index (CCI), All Patient Refined Diagnosis Related Groups (APR-DRG) scores, and indirectly by place of receiving care, length of stay (LOS), cost of stay, type of insurance, and emergency department admissions. LOS increased with age, in males in the Northeast, and was less in whites compared to other races. Trend analysis showed a decrease in LOS and costs from 2010 to 2015. Increased costs were seen in non-whites, males, higher household income based on zip code, being covered under Medicaid, transfers, CCI ≥ 5, and discharges in the western US. Median household income based on the patient's zip code was well-balanced between those who lived and those who died (P = 0.091). However, payers were not evenly distributed between the two groups (P < 0.0001 for the overall comparison). A higher proportion of discharges associated with in-hospital mortality were covered under Medicare (70% vs. 65% in the died vs. lived groups, respectively). Fewer discharges were associated with death if they were covered by commercial insurance or paid for out-of-pocket (15% vs. 19% for commercial insurance and 3% vs. 5% for out-of-pocket). In-hospital mortality was associated with a longer length of hospital stay (5.6 days vs. 4.5 days; P < 0.0001) and higher costs ($16,815 vs. $11,859; P < 0.0001). Variables that were significantly associated with lower total costs were older age, having commercial insurance, paying out-of-pocket or other payers, not being admitted through the emergency department, having a lower comorbidity index (CCI = 1-2), and being discharged from a hospital that was small- or medium-sized, located in the Midwest or South, and/or was non-teaching (rural or urban).

Primary Intracranial Hemorrhage: Characteristics, Distribution, Risk Factors, and Outcomes-A Comparative Study between Jewish and Arab Ethnic Groups in Northern Israel

Background and purpose: This study aimed to investigate the differences in intracerebral hemorrhage (ICH) between Jews and Arabs residing in northern Israel, focusing on risk factors, hemorrhage volume, and functional outcome. Methods: A retrospective analysis was conducted utilizing a population-based registry to investigate intracerebral hemorrhage (ICH) characteristics, risk factors, and outcomes. The registry consisted of inpatients diagnosed with hemorrhagic stroke. Due to the wide variation in data on ICH characteristics and the limited availability of population-based data on predictors of ICH survival and functional outcomes, we collected retrospective data on all adult patients admitted to the Galilee Medical Center with a diagnosis of ICH. Data were obtained from the registry covering the period from 2013 to 2019. Ethnic differences and risk factors associated with intracranial hemorrhage (ICH) were examined within a diverse population of 241 patients, comprising 52.70% Jews (n = 127) and 47.30% Arabs (n = 114). Results: The results of this study revealed significant differences in age, obesity rates, and intracerebral hemorrhage (ICH) location between the two ethnic groups. Hypertension emerged as the most prevalent condition among ICH patients in both ethnic groups (76.70%), followed primarily by anticoagulant use (63.60%), dyslipidemia (60.70%), diabetes (44.60%), obesity (30.60%), smoking (24.60%), and a history of cardiovascular disease (21.80%). Furthermore, 20.90% of the patients had a history of previous cerebrovascular accidents (CVA). Arab patients with ICH were generally younger (62.90 ± 16.00 years) and exhibited higher rates of obesity (38.70%) compared to Jewish patients with ICH (70.17 ± 15.24 years, 23% obesity; p = 0.001, p = 0.013, respectively). Hemorrhage volume was identified as a crucial determinant of patient outcomes, with larger volumes associated with poorer Modified Rankin Scale (mRS) scores at discharge and higher mortality rates. Interestingly, patients without hypertension had higher hemorrhage volumes compared to those with hypertension. The extent of hemorrhage into the ventricles did not significantly correlate with mRS at discharge in our dataset. Conclusions: This study highlights significant differences in the characteristics and outcomes of intracranial hemorrhage (ICH) between Jews and Arabs in northern Israel. The findings reveal variations in age, obesity rates, and ICH location between the two groups. While hypertension was the most prevalent risk factor for both populations, other risk factors differed. Notably, hemorrhage volume emerged as a crucial prognostic factor, aligning with previously published data. These findings underscore the necessity for tailored approaches that consider ethnic-specific factors in the risk assessment, prevention, and management of ICH. Further research is warranted to elucidate the underlying mechanisms and develop interventions aimed at improving outcomes and enhancing healthcare practices in ICH management.

Characteristics and Long-Term Outcome of Cerebellar Strokes in a Single Health Care Facility in Mexico

Objective

The purpose of this study was to analyze and discuss the clinical characteristics, long-term outcome, and prognostic factors of cerebellar strokes treated in a single health care facility in Mexico.

Methods

We retrospectively reviewed the medical records of adult patients admitted to our hospital with diagnosis of cerebellar ischemic and hemorrhagic stroke between 2018 and 2020. Baseline data included sociodemographic and radiological variables, treatment (surgical versus conservative), and Glasgow Coma Scale on arrival (GCSOA). The final neurological outcome was evaluated with the Glasgow Outcome Scale (GOS) six months after hospital discharge.

Results

Ten patients (seven male and three female) with a mean age of 57.9 ± 9.3 years were included, six with cerebellar ischemic infarction and four with cerebellar hemorrhage. Out of the 10 patients, four underwent surgery (suboccipital decompressive craniectomy {SDC} ± ventriculostomy). The outcome was favorable in four cases (40%) and unfavorable in six (60%). Patients who underwent surgical treatment fared worse with all four cases associating poor outcome. The comparison between good and poor outcome groups showed significant differences in the presence of obstructive hydrocephalus (one versus six, p = 0.05) and poorer GCSOA (6.16 ± 1.72 versus 12.5 ± 3.6, p = 0.05), associating poorer outcome.

Conclusion

There is still controversy regarding the appropriate management of cerebellar strokes. The presence of obstructive hydrocephalus and poorer GCSOA are associated to worse outcomes.

Comparison of Long-Term Outcomes of Endoscopic and Minimally Invasive Catheter Evacuation for the Treatment of Spontaneous Cerebellar Hemorrhage

Recently, minimally invasive techniques, including endoscopic evacuation and minimally invasive catheter (MIC) evacuation, have been used for the treatment of patients with spontaneous cerebellar hemorrhage (SCH). However, credible evidence is still needed to validate the effects of these techniques. To explore the long-term outcomes of both surgical techniques in the treatment of SCH. Fifty-two patients with SCH who received endoscopic evacuation or MIC evacuation were retrospectively reviewed. Six-month mortality and the modified Rankin Scale (mRS) score were the primary and secondary outcomes, respectively. A multivariate logistic regression model was used to assess the effects of the different surgical techniques on patient outcomes. In the present study, the mortality rate for the entire cohort was 34.6%. Univariate analysis showed that the surgical technique and preoperative Glasgow Coma Scale (GCS) score affected 6-month mortality. However, no variables were found to be correlated with 6-month mRS scores. Further multivariate analysis demonstrated that 6-month mortality in the endoscopic evacuation group was significantly lower than that in the MIC evacuation group (OR = 4.346, 95% CI 1.056 to 17.886). The 6-month mortality rate in the preoperative GCS 9-14 group was significantly lower than that in the GCS 3-8 group (OR = 7.328, 95% CI 1.723 to 31.170). Compared with MIC evacuation, endoscopic evacuation significantly decreased 6-month mortality in SCH patients. These preliminary results warrant further large, prospective, randomized studies.

Predictive Factors of 2-Year Postoperative Outcomes in Patients with Spontaneous Cerebellar Hemorrhage

Spontaneous cerebellar hemorrhage (SCH) is associated with high patient mortality and morbidity, but the clinical and radiographic predictors of the postoperative outcome have not been widely addressed in the literature. The purpose of this study was to define the prognostic factors for the two-year postoperative outcome in patients with SCH. We conducted a retrospective study of 48 consecutive patients with SCH who underwent neurosurgical intervention. Correlation analysis was performed to examine the possible link between clinical and radiographic parameters, and the National Institutes of Health Stroke Scale (NIHSS) score at each patient’s discharge and the two-year postoperative outcome as defined according to the Glasgow outcome scale (GOS). A total of 48 patients with SCH underwent neurological surgery, which included suboccipital craniectomy and/or external ventricular drainage (EVD). The mean patient age was 63 years. Nine patients underwent suboccipital craniectomy only; 38 underwent both suboccipital craniectomy and EVD. The overall mortality rate was 35.4%. Fourteen patients (29.2%) had good outcomes. A good outcome on the GOS at 2 years after surgical treatment of SCH was associated with the NIHSS score at discharge. An increase of one point in a patient’s NIHSS score at discharge following neurological surgery will increase the probability of a poor two-year postoperative outcome by 28.5%.

Prediction of 30-day mortality in spontaneous cerebellar hemorrhage

Background:

Cerebellar hemorrhage is a potentially life-threatening condition and an understanding of the factors influencing outcome is essential for sound clinical decision-making.

Methods:

We retrospectively evaluated data from 50 consecutive patients who suffered a first spontaneous cerebellar hemorrhage (SCH) from 2005 to 2014, analysing their short-term outcomes and identifying possible clinical, radiological and therapeutic risk factors for poor prognosis and death within 30 days.

Results:

Among 50 patients with first SCH, the mean age was 72 ± 10 years. Median Glasgow Coma Scale (GCS) score on admission was 11 [interquartile range (IQR) = 7–11]. Among 50 patients, 19 patients (38%) underwent surgical hemorrhage evacuation with placement of an external ventricular drain (EVD), 12 patients (24%) received an EVD only and 19 patients (38%) were treated conservatively. The 30-day mortality rate was 36%. In multivariate analysis only the GCS score on admission was a significant predictor of 30-day mortality [odds ratio (OR) = 0.598; 95% confidence interval (CI) = 0.406–0.879; P = 0.009]. For prediction of 30-day mortality, receiver operating characteristic curve analysis confirmed that the best cut-off point was a GCS score of 10 on admission [area under the curve: 0.882, 95% CI = 0.717–1, P < 0.001].

Conclusion:

Lower GCS score on admission was associated with increased 30-day mortality and poorer short-term outcome in patients with SCH. For patients with a GCS score <10 on admission, it is important to balance the possibility of survival afforded by further therapy against the formidable risk of significant functional disability and poor quality of life.

Critical Care Management of Acute Ischemic Stroke

OPINION STATEMENT

Ischemic stroke accounts for approximately 85% of all strokes. Although severe strokes constitute a minority of cases, they are associated with a majority of the subsequent disability and death. Reperfusion therapy with intravenous tissue plasminogen activator (tPA) and/or endovascular thrombectomy is a mainstay of acute stroke management. Intensive care management of stroke is focused on reducing complications of reperfusion, such as hemorrhagic transformation, and minimizing secondary brain injury, including brain edema and progressive stroke. Additionally, severe stroke patients frequently need ventilatory or hemodynamic support provided in an intensive care unit (ICU) setting. Here, we discuss the current medical and surgical ICU management aspects of acute ischemic stroke and identify areas where ongoing studies may reveal new treatments to improve neurological recovery.

Spontaneous Cerebellar Hematoma: Decision Making in Conscious Adults

OBJECTIVE

To detect predictors of the clinical course and outcome of cerebellar hematoma in conscious patients that may help in decision making.

METHODS

This study entails retrospective and prospective review and collection of the demographic, clinical, and radiologic data of 92 patients with cerebellar hematoma presented conscious and initially treated conservatively. Primary outcome was deterioration lower than a Glasgow Coma Scale score of 14 and secondary outcome was Glasgow Outcome Scale score at discharge and 3 months later. Relevant data to primary outcome were used to create a prediction model and derive a risk score. The model was validated using a bootstrap technique and performance measures of the score were presented. Surgical interventions and secondary outcomes were correlated to the score to explore its use in future decision making.

RESULTS

Demographic and clinical data showed no relevance to outcome. The relevant initial computed tomography criteria were used to build up the prediction model. A score was derived after the model proved to be valid using internal validation with bootstrapping technique. The score (0-6) had a cutoff value of ≥2, with sensitivity of 93.3% and specificity of 88.0%. It was found to have a significant negative association with the onset of neurologic deterioration, end point Glasgow Coma Scale scores and the Glasgow Outcome Scale scores at discharge. The score was positively correlated to the aggressiveness of surgical interventions and the length of hospital stay.

CONCLUSIONS

Early definitive management is critical in conscious patients with cerebellar hematomas and can improve outcome. Our proposed score is a simple tool with high discrimination power that may help in timely decision making in those patients.

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.

Integrating Palliative Care Into the Care of Neurocritically Ill Patients: A Report From the Improving Palliative Care in the ICU Project Advisory Board and the Center to Advance Palliative Care

OBJECTIVES

To describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; to discuss key prognostic aids and their limitations for neurocritical illnesses; to review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; and to describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill.

DATA SOURCES

A search of PubMed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term "palliative care," "supportive care," "end-of-life care," "withdrawal of life-sustaining therapy," "limitation of life support," "prognosis," or "goals of care" together with "neurocritical care," "neurointensive care," "neurological," "stroke," "subarachnoid hemorrhage," "intracerebral hemorrhage," or "brain injury."

DATA EXTRACTION AND SYNTHESIS

We reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert advisory board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting.

CONCLUSIONS

Most neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support will provide clinicians a framework to address decision making at a time of crisis that enhances patient/family autonomy and clinician professionalism.

Management and Outcome of Spontaneous Cerebellar Hemorrhage

Objective

Spontaneous cerebellar hemorrhage (SCH) is less common than supratentorial intracerebral hemorrhage. This study investigated the treatment of SCH and the relation between its clinical and radiological manifestation and outcome.

Materials and Methods

We presented a SCH management protocol in our institute and analyzed the clinical and radiological findings in 41 SCH patients. The outcomes of each method (surgery and conservative treatment) were compared among patients with initial Glasgow Coma Scale (GCS) score of 9-13 and hematoma volume greater than 10 mL.

Results

Two (4.9%), 16 (39%), and 23 (56.1%) patients had an initial GCS score of 3-8, with 3-8, 9-13, and 14-15, respectively. Initial GCS score showed significant correlation with Glasgow Outcome Scale (GOS) score (p = 0.005). The mean largest hematoma diameter was 3.2 ± 1.5 cm, and the mean volume was 11.0 ± 11.5 mL. Both of them showed significant inverse correlation with GOS score (p < 0.001). Among patients with an initial GCS score of 9-13 and hematoma volumes greater than 10 mL, 3 (50%) had good outcome and 3 (50%) had poor outcome in the surgical, and all of those in the conservative treatment group had poor outcomes. The outcome distribution differed significantly in the surgical and conservative groups (p = 0.030).

Conclusion

Initial GCS score and largest hematoma diameter and volume on brain computed tomography are important determinants of outcome in SCH patients. The surgery group showed better outcome than the conservative treatment group among those with an intermediate neurological status and large hematomas.

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 (> 6months) 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.

Platelet count and early outcome in patients with spontaneous cerebellar hemorrhage: a retrospective study

INTRODUCTION

The importance of coagulation, hematology, and biochemical variables have been investigated in the stroke population but have not been systemically surveyed in cerebellar hemorrhage (CH) population. The aim of the study was to explore the predictive value of these factors for early outcome in this population.

MATERIALS AND METHODS

Eighty patients with acute spontaneous CH were retrospectively analyzed. Clinical and laboratory data were collected on admission for analysis. The patients were divided by Glasgow outcome scale (GOS) score at discharge into the good outcome group (GOS score 4 or 5) and the poor outcome group (GOS score 1, 2, or 3). The association between early outcome and clinical or laboratory variables were investigated by binary logistic regression.

RESULTS

There were 46 (57.5%) patients in the poor outcome group and 34 (42.5%) in the good outcome group. The platelet count (PC) was significantly lower in the poor outcome group (187.3 ± 53.0 × 10(9)/l) compared with good outcome group (244.9 ± 63.9 × 10(9)/l) (p < 0.001). Moreover, PC (OR 0.97; p = 0.004) was the strong predictor with poor early outcome.

CONCLUSIONS

We firstly show that lower PC is the independent predictor for poor early outcome in patients with spontaneous CH.

Cerebellar strokes: a clinical outcome review of 79 cases

INTRODUCTION

Cerebellar infarcts and haemorrhages are relatively uncommon, accounting for less than 10% of all strokes. The objective of the present study was to quantify and compare the outcomes of patients with cerebellar infarct and those of patients with cerebellar haemorrhage, as well as to identify the risk factors that predict poor outcome in patients with cerebellar stroke.

METHODS

We retrospectively reviewed the medical records of consecutive patients admitted to National University Hospital, Singapore, between 2004 and 2006, within one week of cerebellar stroke onset. Baseline data included demographics, concomitant comorbidities, and the presence or absence of brainstem compression and hydrocephalus (on computed tomography or magnetic resonance imaging). The Glasgow Outcome Scale and modified Rankin Score were used to assess outcome at discharge and at six months after discharge.

RESULTS

A total of 79 patients with cerebellar stroke were admitted during the study period. Of these 79 patients, 17.7% died and 31.6% had poor outcomes at six months after discharge. Patients with cerebellar haemorrhage were found to be more likely to have poor outcomes as compared to patients with cerebellar infarct, both at discharge (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.3-14.1) and at six months after discharge (OR 5.2, 95% CI 1.6-17.2). When compared to small lesions (< 5 cm(3)), lesions > 20 cm(3) were significantly associated with poorer outcomes and the development of hydrocephalus and brainstem compression.

CONCLUSION

Cerebellar strokes are a significant cause of morbidity and mortality. The outcomes of patients with cerebellar haemorrhage are more likely to be worse than those of patients with cerebellar infarct.

Spontaneous intracerebral and intraventricular hemorrhage: advances in minimally invasive surgery and thrombolytic evacuation, and lessons learned in recent trials

Optimal management of spontaneous intracerebral hemorrhage (ICH) remains one of the highly debated areas in the field of neurosurgery. Earlier studies comparing open surgical intervention with best medical management failed to show a clear benefit. More recent experience with minimally invasive techniques has shown greater promise. Well-designed phase II trials have confirmed the safety and preliminary treatment effect of thrombolytic aspiration and clearance of spontaneous ICH and associated intraventricular obstructive hemorrhage. Those trials are reviewed, including respective protocols and technical nuances, and lessons learned regarding patient selection, the concept of hemorrhage stabilization, optimization of the surgical procedure, and thrombolytic dosing decisions. These concepts have been incorporated in the design of ongoing definite phase III randomized trials (MISTIE and CLEAR) funded by the National Institutes of Health. These are presented including the role of surgical leadership in the training and monitoring of the surgical task and quality assurance. The impact of these techniques on neurosurgical practice is discussed.

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.

Thrombolytic evacuation of intracerebral and intraventricular hemorrhage

Intracranial hemorrhage (ICH) accounts for 10-15 % of all strokes, however it causes 30-50 % of stroke related mortality, disability and cost. The prevalence increases with age with only two cases/100,000/year for age less than 40 years to almost 350 cases/100,000/year for age more than 80 years. Several trials of open surgical evacuation of ICH have failed to show clear benefit over medical management. However, some small trials of minimal invasive hematoma evacuation in combination with thrombolytics have shown encouraging results. Based on these findings larger clinical trials are being undertaken to optimize and define therapeutic benefit of minimally invasive surgery in combination with thrombolytic clearance of hematoma. In this article we will review some of the background of minimally invasive surgery and the use of thrombolytics in the setting of ICH and intraventricular hemorrhage (IVH) and will highlight the early findings of MISTIE and CLEAR trials for these two entities respectively.

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.

External ventricular drainage for intraventricular hemorrhage

Hemorrhagic stroke accounts for only 10% to 15% of all strokes; however, it is associated with devastating outcomes. Extension of intracranial hemorrhage (ICH) into the ventricles or intraventricular hemorrhage (IVH) has been consistently demonstrated as an independent predictor of poor outcome. In most circumstances the increased intracranial pressure and acute hydrocephalus caused by ICH is managed by placement of an external ventricular drain (EVD). We present a systematic review of the literature on the topic of EVD in the setting of IVH hemorrhage, articulating the scope of the problem and prognostic factors, clinical indications, surgical adjuncts, and other management issues.

Management of acute intracranial and intraventricular hemorrhage

OBJECTIVE

Acute intracranial hemorrhage and intraventricular hemorrhage are devastating disorders. The goal of this review is to familiarize clinicians with recent information pertaining to the acute care of intracranial hemorrhage and intraventricular hemorrhage.

DATA SOURCES

PubMed search and review of the relevant medical literature.

SUMMARY

The management of intracranial hemorrhage and intraventricular hemorrhage is complex. Effective treatment should include strategies designed to reduce hematoma expansion and limit the medical consequences of intracranial hemorrhage and intraventricular hemorrhage. At present, there are a number of new approaches to treatment that may reduce mortality and improve clinical outcomes. Clinicians should recognize that patients with large hematomas may make a substantial recovery.

CONCLUSIONS

Patients with intracranial hemorrhage and intraventricular hemorrhage should be cared for in an intensive care unit. New therapies designed to stabilize hematoma growth and reduce hematoma burden may improve outcomes.

Epidemiologic predictors of 30-day survival in cerebellar hemorrhage

BACKGROUND

Outcome after cerebellar hemorrhage is relatively poorly understood.

OBJECTIVES

To describe cerebellar hemorrhage and to establish if there were epidemiologic risk factors associated with early mortality.

METHODS

Computerized records were searched to identify intracerebral hemorrhage (ICD-9-CM code 431) from 1986 to 1996 at 2 hospitals. Charts were abstracted using a standardized protocol. The provincial vital statistics registry was used to confirm mortality data. A multivariable logistic regression model was developed to identify predictors of 30-day mortality.

RESULTS

Of 629 identified cases of intracerebral hemorrhage, 79 (12.5%) were cerebellar. The 30-day mortality was 41.7%. Approximately one third (31.7%) had an identifiable underlying cause. The odds of survival at 30 days was significantly reduced (odds ratio = 0.24; 95% confidence interval, 0.08 to 0.74) if the hemorrhage was caused by an identifiable underlying cause.

CONCLUSIONS

Cerebellar hemorrhage with an underlying cause is more likely to be fatal than idiopathic or hypertensive cerebellar hemorrhage.

Psychogenic tremor disorders identified using tree‐based statistical algorithms and quantitative tremor analysis

Detecting psychogenic tremors (PsychT) is often challenging. As there are no laboratory investigations or imaging techniques that can confirm the diagnosis, PsychT is identified on a clinical basis. We present a tree-based statistical algorithm derived from quantitative computerized tremor recordings as a novel method to help in the recognition of PsychT. The goal of this study was to show that objective data from computerized tremor recordings, when processed through a tree-based statistical algorithm, can be used to determine whether a patient can be classified as having PsychT.

Hypertensive caudate hemorrhage prognostic predictor, outcome, and role of external ventricular drainage

BACKGROUND AND PURPOSE

The purpose of the present study was to analyze the outcome and outcome predictors of caudate hemorrhage and role of external ventricular drainage in acute hydrocephalus.

METHODS

Clinical data from 36 consecutive patients with hypertensive caudate hemorrhage was used in the present study. Age, gender, volume of parenchymal hematoma, hematoma in the internal capsule, initial Glasgow Coma Scale (GCS), hydrocephalus, severity of intraventricular hemorrhage, and hemorrhagic dilatation of the fourth ventricle were analyzed for effect on outcome. Effect of external ventricle drainage for hydrocephalus was evaluated by comparing preoperative and postoperative GCS scores.

RESULTS

By univariate analyses, poor outcome was associated with a poor initial GCS score (P=0.016), hydrocephalus (P<0.001), intraventricular hemorrhage severity (P<0.01), and hemorrhagic dilatation of the fourth ventricle (P=0.02). By multivariate analysis, stepwise logistic regression revealed that hydrocephalus was the only independent prognostic factor for poor outcome (P<0.001). Postoperative 48-hour GCS score was better than the preoperative score by use of paired-sample t test (P<0.001).

CONCLUSIONS

Hydrocephalus is the most important predictor of poor outcome. External ventricular drainage response for hydrocephalus was good in the present study, whereas an early decision should be made regarding preoperative neurological condition.