Since then, surgical treatment has become the general option for treatment 3).
Recommendations from Kobayashi et al in 1994 4)
1. patients with a Glasgow Coma Scale (GCS) score ≥14 and hematoma <4 cm diameter: treat conservatively
2. patients with GCS≤13 or with a hematoma ≥4 cm: surgical evacuation.
3. patients with absent brain stem reflexes and flaccid quadriplegia: intensive therapy is not indi- cated. Note: some authors contend that the loss of brain stem reflexes from direct compression may not be irreversible, 5) and that cerebellar hemorrhage represents a surgical emergency (and that the above criteria would thus deny potentially helpful surgery to some, see discussion of cerebellar infarction and decompression.
4. patients with hydrocephalus: ventricular catheter (if no coagulopathy). Caution: do not overdrain to avoid upward cerebellar herniation. Most cases with hydrocephalus also require evacuation of the clot
Since the 1970s, there has been a wide mutual consensus in the neurological and neurosurgical community that cerebellar ICHs should be operated on. However, the scientific proof is mainly based on small retrospective series with conflicting results 7).
To relieve brainstem compression and hydrocephalus, surgeons tend to favor occipital craniectomy or occipital craniotomy with hematoma evacuation in patients with a declining level of consciousness 8). Some regard this counterintuitive as long-term outcomes after surgical treatment of cerebellar ICH are generally pessimistic 9).
Since the report by Little et al., 10) the hematoma diameter has been considered a significant factor in the decision-making process for optimal treatment.
The criteria for surgery remain controversial, and many researchers have determined that a hematoma larger than 3 cm, obstruction of the quadrigeminal cistern, and compression of the fourth ventricle are surgical criteria 11) 12) 13).
Cohen et al. 14) used a maximal hematoma diameter greater than 3 cm as the surgical criterion, however, some patients with a hematoma larger than 3 cm who underwent conservative treatment had a good prognosis as well. In addition, a hematoma volume greater than 15 mL, being equivalent with a hematoma with a maximal diameter greater than 3 cm, has also been used as a criterion in some cases 15).
The criteria of Kobayashi et al., are as follows:
2) for the patients with Glasgow Coma Scale scores of 13 or less at admission or with a hematoma measuring 40 mm or more, hematoma evacuation with decompressive suboccipital craniectomy should be a treatment of choice
3) for the patient whose brain stem reflexes are entirely lost with flaccid tetraplegia or whose general condition is poor, intensive therapy is not indicated. The validity of these criteria was tested and confirmed in 49 cases 16).
Lateral oblique position with the involved side up.
It is a treatment option for elderly patients with severe SCH + IVH 17).