Spontaneous cerebellar haemorrhage on CT (adult)
Non-traumatic intracerebral haemorrhage (ICH) in the cerebellum. Call neurosurgery early.
All Pathways
NeurosurgeryEmergency
Cerebellar (Posterior Fossa) Haemorrhage - Surgical Decision (AHA/ASA 2022)
Cerebellar (Posterior Fossa) Haemorrhage - Surgical Decision (AHA/ASA 2022): Spontaneous cerebellar haemorrhage on CT (adult) → Check first: brainstem b...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Warning Check first: brainstem bleed, vascular cause, trauma, child
These patients need a different plan. Deteriorating patient: do not delay surgery for vascular imaging; add CTA to the planning CT only if it causes no delay.
- Primary brainstem (pontine) haemorrhage: surgery steps below do not apply; get neurosurgery and ICU advice
- Age <45 y, or 45-70 y with no hypertension: CTA (± venography) to exclude AVM, aneurysm or venous thrombosis
- Trauma or child: use a head injury or paediatric pathway
03Action Assess now: airway, GCS, pupils, brainstem signs, CT findings
Protect the airway if GCS falls or airway reflexes are lost. Check GCS, pupils, cranial nerve signs and breathing pattern for deterioration or brainstem compression.
- CT: haematoma volume (ABC/2), IVH, fourth ventricle, basal cisterns, hydrocephalus
- FBC, INR, aPTT; anticoagulant or antiplatelet use and time of last dose
- Admit to a neuro ICU; no neurosurgery on site: transfer to a neurosurgical centre
- Give full active care unless the patient documented treatment limits before the ICH
04Action Mild to moderate ICH: if SBP 150-220 mmHg, lower SBP to 140 mmHg
SBP >220 mmHg, large ICH or surgery needed: lower with caution and set the SBP target with neurosurgery. Otherwise start within 2 h of onset, reach target within 1 h and titrate smoothly.
- Keep SBP 130-150 mmHg
- Do not lower SBP below 130 mmHg (potentially harmful)
- Avoid peaks, large swings and a fall in SBP of more than 70 mmHg
- IV agent per local protocol (e.g. labetalol, clevidipine). No labetalol in asthma, bradycardia or AV block
05Action On an anticoagulant: stop it and reverse now, before surgery
Give reversal as soon as ICH is diagnosed. Do not wait for the INR if a recent dose is likely. Warfarin: aim INR <1.3 as soon as possible; recheck INR after PCC.
- Warfarin (adult): vitamin K 5-10 mg IV plus 4F-PCC (Beriplex) 50 IU/kg IV, max 5000 IU; lower PCC dose if INR 1.5-1.9. Only Prothrombinex-VF stocked: follow local protocol
- Dabigatran (adult): idarucizumab 5 g IV (2 x 2.5 g)
- Apixaban, rivaroxaban or edoxaban: 4F-PCC. Dose: see local haematology protocol (andexanet alfa is not TGA-registered)
- Heparin or LMWH (enoxaparin): protamine; LMWH is only partly reversed. Dose: see product information
06Action On an antiplatelet: no platelet transfusion unless emergency surgery
Platelet transfusion for antiplatelet-related ICH without surgery is potentially harmful.
- Aspirin and emergency neurosurgery: platelet transfusion may be considered
- Ticagrelor is not reversed by platelet transfusion
- Desmopressin: benefit uncertain
- Any ICH: tranexamic acid and factor VIIa are not established; do not give routinely
07Decision Deterioration, brainstem compression, obstructive hydrocephalus or ICH ≥15 mL?
Any one of these is an indication for immediate surgery. Estimate haematoma volume by ABC/2.
- If Yes
08Warning Surgery indicated: immediate haematoma evacuation, with or without EVD
Surgical removal reduces mortality compared with medical care alone (AHA 2022 COR 1). Functional benefit is not proven.
- Do not use EVD alone for obstructive hydrocephalus: may be harmful (worse if basal cisterns compressed) and may not relieve brainstem compression or ischaemia
- Primary brainstem haemorrhage: this step does not apply
- Reverse anticoagulation before surgery (see above)
09Action Surgery indicated: suboccipital craniectomy and haematoma evacuation
Neurosurgeon chooses the approach. No trial compares techniques.
- Suboccipital decompression plus evacuation: trend to better outcome than evacuation alone (one retrospective study)
- Hydrocephalus: place EVD together with evacuation
- Endoscopic or stereotactic evacuation: evidence limited
10Action After surgery: neuro-ICU care
Continue BP target and correction of coagulation.
- Frequent neuro checks; CT at once if deterioration
- Intermittent pneumatic compression from the day of diagnosis
- Low-dose heparin or LMWH: timing with neurosurgery (may start 24-48 h after ICH onset if stable)
11Outcome Outcome after surgery
Surgery improves survival. Benefit for functional outcome is not proven.
If No12Action No surgical indication now: medical care with close monitoring
For cerebellar ICH <15 mL with no deterioration, no brainstem compression and no hydrocephalus.
- Neuro ICU; frequent neuro checks
- CT at once if GCS falls or new brainstem signs
- Surgery at once if deterioration, brainstem compression or hydrocephalus develops
- Intermittent pneumatic compression from the day of diagnosis. Low-dose heparin or LMWH may start 24-48 h after onset if the haematoma is stable on CT
13Outcome Outcome with medical care
Keep monitoring. Operate if the patient deteriorates.
Guideline Source
AHA/ASA 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults with spontaneous cerebellar ICH only; not for primary brainstem haemorrhage, trauma or children
- No randomised trials: surgery reduces mortality in observational data, but functional benefit is not proven
- Timing of surgery and choice of surgical technique are not established
- Reversal doses are for adults; follow local haematology protocol for DOAC reversal
Contraindicated Populations
ChildrenPrimary brainstem haemorrhageTraumatic posterior fossa haematoma
Applicable Regions
USEUAUGlobal
AU: Andexanet alfa and nicardipine are not on the ARTG. 4F-PCC (Beriplex) is registered; where only Prothrombinex-VF (3F-PCC) is stocked, follow local protocol.
EU: ESO-EANS 2025 ICH guideline: suggests surgical evacuation of cerebellar haematoma >15 mL to improve survival (weak recommendation, very low certainty).
US: AHA/ASA 2022: immediate surgical evacuation, with or without EVD, for cerebellar ICH with deterioration, brainstem compression, obstructive hydrocephalus or volume ≥15 mL (COR 1, LOE B-NR).
Version 2Next review: 2027-09-30
Next steps
Finish the workflow by opening the most relevant calculator, then convert the session into a live account when you are ready.
Related Resources
Frequently Asked Questions
What is the Cerebellar (Posterior Fossa) Haemorrhage - Surgical Decision (AHA/ASA 2022)?
The Cerebellar (Posterior Fossa) Haemorrhage - Surgical Decision (AHA/ASA 2022) is a emergency clinical algorithm for Neurosurgery. It provides a structured decision tree to guide clinical decision-making, based on AHA/ASA 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage.
What guideline is the Cerebellar (Posterior Fossa) Haemorrhage - Surgical Decision (AHA/ASA 2022) based on?
This algorithm is based on AHA/ASA 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage (DOI: 10.1161/STR.0000000000000407).
What are the limitations of the Cerebellar (Posterior Fossa) Haemorrhage - Surgical Decision (AHA/ASA 2022)?
Known limitations include: Adults with spontaneous cerebellar ICH only; not for primary brainstem haemorrhage, trauma or children; No randomised trials: surgery reduces mortality in observational data, but functional benefit is not proven; Timing of surgery and choice of surgical technique are not established; Reversal doses are for adults; follow local haematology protocol for DOAC reversal. Individual patient factors may require deviation from these recommendations.
Get AI-Powered Analysis Alongside This Algorithm
In AttendMe.ai, the Cerebellar (Posterior Fossa) Haemorrhage - Surgical Decision (AHA/ASA 2022) appears automatically when your clinical question matches — alongside evidence from 3M+ peer-reviewed articles.
Try AttendMe Free