Bleeding in the cerebellum – surgery increases chances of survival
Largest meta-analysis of patient data from Germany and the USA has now been published
In Germany, approximately 35,000 people suffer from an acute brain haemorrhage every year. Reliable studies are already available on using surgery to treat intracerebral haemorrhages in the cerebrum. In contrast, the international guidelines for treating haemorrhages in the cerebellum are based on considerably fewer cases. Cerebellar haemorrhages account for only ten percent of all instances of bleeding in the brain. Experts from Germany and the USA have collaborated to investigate for the first time what effect surgical haematoma evacuation has on case fatality rates and the functional outcome in the long term. A total of 64 centres were involved in the analysis, led by Universitätsklinikum Erlangen. The results of the study have now been published in the Journal of the American Medical Association (JAMA).
‘Based on our data and the meta-analysis, we have come to the following conclusion: surgical haematoma evacuation should not be performed on haematomas with a volume of less than 12 cubic centimetres. This would be more likely to lead to a functional deterioration, in other words the patient would be more likely to be left with a lasting physical or motor disability. Furthermore, surgery would not significantly improve the patient’s chances of survival,’ explains Prof. Dr. Hagen Huttner, chief consultant at the Department of Neurology at Universitätsklinikum Erlangen, who led the study. ‘On the other hand, surgery significantly reduces the rate of fatalities for haematomas which have a volume in excess of 15 cubic centimetres in comparison to conservative approaches such as an induced coma or treatment aimed at reducing brain pressure without an operation,’ Prof. Huttner continues. He admits, however, that ‘surgery does not improve the long-term functional outcome. The results for volumes between 12 and 15 cubic centimetres were not significant either.’
The approach commonly taken to surgically evacuate a larger cerebellar haematoma has been based until now on studies of a smaller scale. These were based on the premise that the affected patients were at risk of further clinical deterioration, as the space available to the posterior cranial fossa is restricted and the brain stem may be squashed as a result of the haemorrhage. As this would lead in just a short space of time to the death of the patient, doctors were in favour of surgery in such cases. They assumed that this would not only increase the patient’s chances of survival but also improve their clinical prognosis.
Most conclusive for moderately severe cases
The team led by Prof. Huttner and PD Dr. Joji Kuramatsu, a senior consultant at the Department of Neurology, decided to carry out the systematic meta-analysis that has now been published as no randomised study data or larger observational studies had previously been available. Within the framework of this survey of data from 578 patients suffering from a cerebellar haemorrhage, the largest of its kind in the world, groups of patients who had undergone surgery were compared to those who had been given conservative treatments. ‘The results of our evaluation are conclusive, especially for moderately severe cases,’ explains the lead author of the study, PD Kuramatsu. ‘The results are less conclusive from a statistical point of view for patients suffering from very small or very large haemorrhages.’ Joji Kuramatsu continues, ‘the functionality of the brain 90 days after bleeding commenced is comparable in patients who received surgery to the state of those who were given conservative treatment. However, the results vary greatly depending on the size of the haemorrhage at the outset.’
Improved communication with relatives
‘There is no guarantee that an operation will improve the functional outcome. However, surgery does reduce the rate of fatality. This information is very useful in our daily clinical practice and helps us when communicating with relatives,’ Prof. Huttner summarises. ‘Our survey is the first to investigate in depth an approach which has been taken in neurological-neurosurgical intensive care for decades,’ says Dr. Stefan Schwab, head of the Department of Neurology at Universitätsklinikum Erlangen and former president of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI). PD Kuramatsu adds: ‘The results of our survey have for the first time delivered specific effect sizes which can be referred to when planning future research projects. These are certainly needed, as without prospective randomised studies of this nature, we will still not know, despite our analysis, exactly which patients would benefit from an operation.’
Prof. Dr. Hagen Huttner
Phone: +49 9131 8533001