Controversies in the neurosurgical management of cerebellar hemorrhage and infarction.

Evidence-based guidelines for the management of hemorrhagic and ischemic cerebellar stroke are sparse, and most available data come from Class III studies. As a result, opinions and practices regarding the nature and role of neurosurgical intervention vary widely. A comprehensive literature review was conducted to adjudicate several contentious issues, such as the difference in the management of cerebellar hemorrhage versus infarction, criteria for imaging to exclude an underlying structural lesion, the value of MRI for patient selection, the role of external ventricular drainage, the indications for operative management, the timing of surgical intervention, and various options of surgical technique, among others. Treatment algorithms proposed in several different studies are compared and contrasted. This analysis is concluded by a summary of the recommendations from the American Stroke Association, which advises that patients with cerebellar hemorrhage who experience neurological deterioration or who have brainstem compression and/or hydrocephalus due to ventricular obstruction should undergo surgical evacuation of the hemorrhage as soon as possible, and that initial treatment of such patients with ventricular drainage alone rather than surgical removal of the hemorrhage is not recommended.