A 61-year-old man presents to the hospital with severe nausea and vomiting along with gait imbalance and slurred speech. An initial blood pressure is 242/122 mm Hg. A CT of the head without contrast demonstrates a right cerebellar hemorrhage measuring 4 x 4 cm with compression of the brainstem and encroachment on the fourth ventricle. He is not on any medications. Coagulation studies and platelets are normal. Shortly after presenting to the hospital he becomes obtunded requiring intubation.
Which of the following treatments is most likely to improve his clinical outcome?
An intraparenchymal hemorrhage within the confined space of the posterior fossa can result in brainstem compression and/or obstructive hydrocephalus as illustrated in the case above. Non-randomized trials suggest more favorable outcomes with surgical evacuation of cerebellar hematomas >3 cm in diameter or if the hemorrhage is causing brainstem compression or hydrocephalus.
A phase 3 randomized-control trial testing empiric treatment recombinant activated factor VIIa for acute cerebral hemorrhage showed a reduction in hematoma expansion but did not demonstrate improved functional outcome or survival. Therapeutic hypothermia has not been proven to be effective in intraparenchymal hemorrhage. Hyperosmotic therapy may temporarily hasten cerebral edema but a more definitive intervention is needed in this case. Acute aggressive blood pressure reduction has not convincingly been shown to improve clinical outcomes.