title: Acute Posterior Cranial Fossa Hemorrhage-Is Surgical Decompression Better than Expectant Medical Management?
abstract: To compare the in-hospital mortality and institutional morbidity from medical therapy (MT), external ventricular drainage (EVD) and suboccipital decompressive craniectomy (SDC) following an acute hemorrhagic posterior cranial fossa stroke (PCFH) in patients admitted to the neurosciences critical care unit (NCCU). Retrospective observational single-center cohort study in a tertiary care center. All consecutive patients (n = 104) admitted with PCFH from January 1st 2005-December 31st 2011 were included in the study.
  
  
  
  All patients with a PCFH were identified and confirmed by reviewing computed tomography of the brain reported by a specialist neuroradiologist. Management decisions (MT, EVD, and SDC) were identified from operative notes and electronic patient records.
  
  
  
  Following a PCFH, 47.8 % (n = 11) patients died after EVD placement without decompression, 45.7 % (n = 16) died following MT alone, and 17.4 % (n = 8) died following SDC. SDC was associated with lower mortality compared to MT with or without EVD (χ2test p = 0.006, p = 0.008). Age, ICNARC score, brain stem involvement, and hematoma volume did not differ significantly between the groups. There was a statistically significant increase in hydrocephalus and intraventricular bleeds in patients treated with EVD placement and SDC (χ2test p = 0.02). Median admission Glasgow Coma Scale scores for the MT only, MT with EVD, and SDC groups were 8, 6, and 7, respectively (ranges 3-15, 3-11 and 3-13) and did not differ significantly (Friedman test: p = 0.89). SDC resulted in a longer NCCU stay (mean of 17.4 days, standard deviation = 15.4, p < 0.001) and increased incidence of tracheostomy (50 vs. 17.2 %, p = 0.0004) compared to MT with or without EVD.
  
  
  
  SDC following PCFH was associated with a reduction in mortality compared to expectant MT with or without EVD insertion. A high-quality multicenter randomized control trial is required to evaluate the superiority of SDC for PCFH.
authors.affiliation: School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK.
authors.forename: M S
authors.initials: MS
authors.lastname: Luney
authors.affiliation: Department of Medicine (Critical Care), The Ottawa Hospital, Ottawa, Canada.|Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge, UK.
authors.forename: S W
authors.initials: SW
authors.lastname: English
authors.affiliation: Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge, UK.
authors.forename: A
authors.initials: A
authors.lastname: Longworth
authors.affiliation: Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge, UK.
authors.forename: J
authors.initials: J
authors.lastname: Simpson
authors.affiliation: Critical Care Unit, University Hospital Birmingham NHS Foundation Trust, Edgbaston, UK.
authors.forename: S
authors.initials: S
authors.lastname: Gudibande
authors.affiliation: Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge, UK.
authors.forename: B
authors.initials: B
authors.lastname: Matta
authors.affiliation: Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge, UK.
authors.forename: R M
authors.initials: RM
authors.lastname: Burnstein
authors.affiliation: Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge, UK. tv227@cam.ac.uk.|Critical Care Unit, University Hospital Birmingham NHS Foundation Trust, Edgbaston, UK. tv227@cam.ac.uk.
authors.forename: T
authors.identifier: 0000-0002-4125-8804
authors.initials: T
authors.lastname: Veenith
mesh_terms: D000328:Adult; D000368:Aged; D002543:Cerebral Hemorrhage / Q000188:drug therapy* / Q000401:mortality* / Q000601:surgery*; D003388:Cranial Fossa, Posterior / Q000187:drug effects / Q000473:pathology / Q000601:surgery; D056424:Decompressive Craniectomy / Q000379:methods*; D005260:Female; D015600:Glasgow Coma Scale; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D014696:Ventriculostomy / Q000379:methods*
keywords: Cerebellar hemorrhage; Critical care; External ventricular drain; Infratentorial hemorrhage; Intensive care; Suboccipital decompressive craniectomy; Tracheostomy