This is the current release of the guideline.

"Degrees of Certainty" [Standards, Guidelines, Options] and "Classification of Evidence" [Class I to III] are defined at the end of the "Major Recommendations" field.

Note: All of the following recommendations are at the Options level, supported only by Class III scientific evidence.

Recommendations

Indications

• Patients with mass effect on computed tomographic (CT) scan or with neurological dysfunction or deterioration referable to the lesion should undergo operative intervention. Mass effect on CT scan is defined as distortion, dislocation, or obliteration of the fourth ventricle; compression or loss of visualization of the basal cisterns, or the presence of obstructive hydrocephalus.
• Patients with lesions and no significant mass effect on CT scan and without signs of neurological dysfunction may be managed by close observation and serial imaging.

Timing

• In patients with indications for surgical intervention, evacuation should be performed as soon as possible because these patients can deteriorate rapidly, thus, worsening their prognosis.

Methods

• Suboccipital craniectomy is the predominant method reported for evacuation of posterior fossa mass lesions, and is therefore recommended.

Summary

There are no controlled, prospective clinical trials of treatment using surgical versus nonsurgical management of posterior fossa mass lesions. The available data support rapid evacuation of posterior fossa mass lesions that 1) show CT evidence of mass effect, or 2) result in progressive neurological dysfunction. Moreover, data support expectant management with serial imaging for select cases in which there is neurological stability and no radiological evidence for mass effect.

Definitions:

Degrees of Certainty

Standards: Represent accepted principles of patient management that reflect a high degree of clinical certainty.

Guidelines: Represent a particular strategy or range of management strategies that reflect a moderate degree of clinical certainty.

Options: Are the remaining strategies for patient management for which there is unclear clinical certainty.

Classification of Evidence on Therapeutic Effectiveness

Class I: Evidence from one or more well-designed, randomized, controlled clinical trials, including overviews of such trials

Class II: Evidence from one or more well-designed comparative clinical studies, such as nonrandomized cohort studies, case-control studies, and other comparable studies

Class III: Evidence from case series, comparative studies  with historical controls, case reports, and expert opinion

None provided

The recommendations are all at the Option level, supported only by Class III scientific evidence (e.g., evidence from case series, comparative studies with historical controls, case reports, and expert opinion)

Not applicable: The guideline was not adapted from another source.

2006 Mar

Brain Trauma Foundation - Disease Specific Society

Brain Trauma Foundation
Integra NeuroSciences

Not stated

Authors: M. Ross Bullock, MD, PhD, Department of Neurological Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia; Randall Chesnut, MD, Department of Neurological Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, Washington; Jamshid Ghajar, MD, PhD,  Department of Neurological Surgery, Weil Cornell Medical College of Cornell University, New York, New York; David Gordon, MD, Department of Neurological Surgery, Montefiore Medical Center, Bronx, New York; Roger Hartl, MD, Department of Neurological Surgery, Weil Cornell Medical College of Cornell University, New York, New York; David W. Newell, MD,  Department of Neurological Surgery, Swedish Medical Center, Seattle, Washington; Franco Servadei, MD, Department of Neurological Surgery, M. Bufalini Hospital, Cesena, Italy; Beverly C. Walters, MD, MSc, Department of Neurological Surgery, New York University School of Medicine, New York, New York; Jack E. Wilberger, MD, Department of Neurological Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania

Not stated

Congress of Neurological Surgeons - Professional Association

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on August 15, 2006. The information was verified by the guideline developer on August 18, 2006.

This is a limited license granted to NGC, AHRQ and its agent only. It may not be assigned, sold, or otherwise transferred. BTF owns the copyright. For any other permission regarding the use of these guidelines, please contact the Brain Trauma Foundation.