A 70 y.o. male presents with altered mental status
What needs to be done?
Our patient presented with obstructive hydrocephalus from a cerebellar bleed. He had a bp of 231/157 on arrival and altered mental status. He had a hx of previous cva with a R basal ganglia hemorrhage and had residual L sided weakness.
When is cerebellar bleeding treated with surgery?
If any of the listed conditions are met surgery is recommended.
Disturbance of consciousness
Signs of brainstem compression
Hematoma with diameter of greater than 3 cm or causing cerebral edema.
The mortality associated with cerebellar hemorrhage can range from 25-57% related to the patient’s clinical status but outcomes are favorable in over half of the cases.
Why aren’t supratentorial bleeds taken to surgery?
Two large randomized , multicenter trials the International Surgical Trial in Intracerebral Hemorrhage I and II, have shown no clinical benefit for early surgical evacuation of intraparenchymal supratentorial hemorrhage. In these trials there were high rates of cross over from the non surgical groups to the surgical groups.
while hypertensive bleeds and cerebral amyloid angiopathy can both involve the cerebellum; CAA can also be found in the periphery.
Cerebellar bleeds are often associated with hypertension but they can also be associated with cerebral amyloid angiopathy (CAA) in 15% of cases. In CAA, hypertension is not the cause of bleeding but rather deposition of amyloid in vessel walls causing endothelial damage and eventual rupture. Cerebral amyloid involves amyloid beta which is distinct from systemic amyloid associated with transthyretin deposits ( ATTR cardiac amyloidosis).
Congo red staining and birefringence in polarized light showing cerebral amyloid beta in cerebral vessels
Our patient underwent an emergent posterior fossa decompression with C1 laminectomy and R frontal external ventricular drain. Currently he is awake, has 4/5 strength on the R side and a L gaze preference. He follows commands and spontaneously opens his eyes.
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