Treatment strategies, complications, and outcomes in spontaneous cerebellar hemorrhage

Acta Neurochirurgica (2026) 168:99

This single-center observational study examines treatment strategies, complications, and outcomes in 194 adults with spontaneous cerebellar hemorrhage (sCH) managed at a Swedish neurointensive care unit between 2008–2024. It compares conservative care, external ventricular drainage (EVD) alone, and combined hematoma evacuation with suboccipital decompression plus EVD, reporting short- and long-term mortality, functional outcome at discharge, and procedure-related complications.

Key findings show that conservative management often succeeds for neurologically stable patients with moderate hematomas (>15 mL), while combined evacuation/decompression with EVD is safe and effective for more severe presentations; EVD alone can suffice for selected hydrocephalus-predominant cases. Age, admission neurological status (GCS M), and hematoma volume independently predict 6-month mortality and functional outcome.

Study design Retrospective single-center cohort of adults with primary spontaneous cerebellar hemorrhage treated in a neurointensive care unit in Uppsala, Sweden (2008–2024), comparing conservative vs surgical management and analyzing predictors of 6‑month mortality and discharge functional outcome (GODS).

Treatment selection About half of 194 patients underwent surgery; surgically treated patients typically had worse neurological status, larger hematoma volumes, and more posterior fossa mass effect (e.g., fourth ventricle compression/hydrocephalus/IVH).

Conservative strategy for stable moderate-large bleeds In awake/stable patients with hematomas >15 mL initially managed conservatively, 78% did not need delayed surgery and most achieved favorable outcomes.

Surgical approach and safety Combined hematoma evacuation with suboccipital decompression plus EVD was associated with low complication rates and low early mortality in this cohort.

EVD-only option in selected cases Some patients with hydrocephalus and smaller hemorrhages were successfully treated with EVD alone, suggesting this may suffice when hydrocephalus predominates without dominant infratentorial mass effect.

Outcomes Overall mortality was 11% at discharge and 28% at 6 months; discharge outcomes differed by treatment group (higher early mortality but higher favorable discharge outcome in conservatively managed patients), while 6‑month mortality was similar between groups.

Key prognostic factors Age, neurological status (GCS motor score), and hematoma volume independently predicted 6‑month mortality; GCS motor score and hematoma volume independently predicted favorable discharge outcome (GODS > 3).

Clinical implication Favorable outcomes were achievable even in elderly patients; conservative care fit neurologically stable patients with moderate volumes, while surgery/EVD pathways were used for more severe presentations or deterioration.