Treatment of spontaneous intracerebral and intracerebellar hemorrhages

Most primary intracerebral and intracerebellar hemorrhages are hypertensive, and the most common site is the basal ganglion. In typical basal ganglia hematoma, surgery offers no benefit, and such patients should be treated conservatively. Surgery is not indicated in pontine hematomas either. Cerebellar hematomas may block the circulation of the cerebrospinal fluid and cause an acute life-threatening hydrocephalus; therefore such hematomas should be operated on. Subcortical hematomas, which are usually not associated with hypertension and may be due to tumor or vascular malformation, should as a rule be operated on. Carotid angiography is necessary for most supratentorial hematomas to exclude the presence of aneurysm or arteriovenous malformation. Secondary hematomas from ruptured arterial aneurysm should be operated on as urgently as traumatic intracranial hematomas if the patient's level of consciousness is deteriorating and if there is severe neurological deficit. Hematomas due to arteriovenous malformation must sometimes be evacuated as an emergency measure if the patient is unconscious, and the malformation should be excised if technically possible. The operation should preferably be postponed to the second week after the bleeding if the patient's level of consciousness is not deteriorating, since the malformation is more easily excised after the brain edema has subsided. Hematomas associated with anticoagulant treatment should be evacuated if the hematoma is expansive and if the patient is unconscious or somnolent but the results are not very good. Hematomas of hemophiliacs should be evacuated, and these patients need an appropriate replacement therapy.