Abstract Purpose Spontaneous cerebellar hemorrhage (sCH) is associated with high mortality, but favorable outcomes can be achieved with appropriate surgical management. We evaluated treatment strategies, complications, outcomes, and prognostic factors in sCH patients at a tertiary center. Methods Adults with primary sCH treated at the neurointensive care unit in Uppsala, Sweden, between 2008 and 2024 were retrospectively included. Clinical and radiological data were collected. Patients were managed conservatively or surgically according to institutional protocols. Outcomes were mortality at discharge and 6 months, and functional outcome at NIC discharge assessed with the Glasgow Outcome Scale-Discharge (GODS). Predictors of 6-month mortality and favorable outcome (GODS > 3) were analyzed. Results A total of 194 patients were included; 50% underwent surgery. Surgically treated patients had lower admission Glasgow Coma Scale motor scores, larger hematoma volumes, and more infratentorial mass effect. Among awake patients with hematomas > 15 mL initially managed conservatively, 78% did not require delayed surgery and most achieved favorable outcomes. Combined hematoma evacuation, suboccipital decompression, and external ventricular drainage (EVD) was associated with low complication rates and low early mortality. Selected patients with hydrocephalus and smaller hemorrhages were successfully treated with EVD alone. Overall mortality was 11% at discharge and 28% at 6 months. Age, neurological status, and hematoma volume independently predicted mortality. Conclusions Favorable outcomes after sCH are achievable, including in elderly patients. Conservative management is appropriate in neurologically stable patients with moderate hematoma volumes, while EVD alone may suffice in selected cases with isolated hydrocephalus.
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