Sklifosovsky Research Institute of Emergency Care,
Chair of Neurosurgery of the Moscow State Medical-Stomatologic University, Moscow, Russia
Cerebellum and brain stem hematomas are hypertensive hemorrhages with the most severe course. Mortality in this group of patients is considerable. However, surgical intervention allows to achieve positive results in some of them.
The goal of the present study was analysis of results of surgical treatment in patients with subtentorial hypertensive hemorrhages.
Materials and Methods. We analyzed operations, performed in 20 cases (19 with cerebellar hemorrhages and 1 with brain stem hemorrhage). There were 14 males and 6 females, aged 37-72. A state of consciousness was as follows: clear consciousness - 4 patients, torpor - 11 cases, sopor - 3 cases and coma - 2 cases. Cerebellar, pyramidal and dislocation symptoms were watched in 11, 14, and 16 cases respectively. Hemorrhage was verified with CT-examination of the brain. A hematoma volume varied from 5 up to 30 cm3. Ventricular hemorrhage was present in 12 patients (60%). Dislocation of the IV ventricle, deformity of the ambient cistern and occlusive hydrocephalus were watched in 13, 15 and 16 cases (80%) respectively.
Brain stem compression and development of occlusive hydrocephalus were indication for an operation. The interventions were performed on the 1 day (7cases), the 2 day (6 cases), the third day (1 case), the 4-8 days (5 cases) and the 14 day (1 case). Craniotomy and local fibrinolysis were used for hematoma removal in 14 and 2 patients respectively. Ventricular drainage as the only means of treatment was applied in 4 cases in an extremely severe state or in small intracerebral hematoma and hemotamponade of the IV ventricle. Duration of external ventricular drainage was 3-8 days. Repeated hemorrhages were observed in 2 cases.
Results. Complete recovery took place in 6 cases. Moderate disability was watched in 3 patients; 11 patients died (55%). Results of surgical treatment were dependent on a degree of consciousness disorder (p<0.01). Fatal outcomes were observed in 6 out of 11 cases with torpor, 2 out of 3 cases with spoor and all patients with coma (2). As for cases with clear consciousness, 1 out of 4 patients died because of repeated hemorrhage. Hematoma volume had no effect on treatment results (p>0.05). Distribution of unfavorable outcomes was as follows: hematoma of less than 10 cm3 - 1 out of 3 cases, hematoma of 11-15 cm3 - all 3 cases, hematoma of 16-20 cm3 - 4 our of 7 cases, hematoma of more than 20 cm3 - 3 out of 7 cases.
Hydrocephalus developed in hemotamponade or compression of the IV ventricle. Presence of ventricular hemorrhage and occlusive hydrocephalus were unfavorable prognostic factors. Fatal outcomes took place in 8 out of 12 cases with ventricular hemorrhage and 3 out of 8 cases without it. As for occlusive hydrocephalus, 10 out of 16 patients with it and 3 out of 8 patients without it died. We failed to reveal dependence of the rate of fatal outcomes on a term of intervention, deformity of the ambient cistern and dislocation of the IV ventricle. Craniotomy resulted in death of 8 out of 14 cases. Drainage of ventricles or hematoma was a cause of death in 3 out of 6 patients.
Conclusion. Risk factors of unfavorable outcome in surgical treatment of subtentorial hypertensive hemorrhages include sopor or coma, ventricular hemorrhage and occlusive hydrocephalus.
Hemorrhages into the posterior cranial fossa can be treated with local fibrinolysis, combined with ventricular drainage or without it.