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## Complete Summary

#### GUIDELINE TITLE

Surgical management of posterior fossa mass lesions.

#### BIBLIOGRAPHIC SOURCE(S)

Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, Servadei
F, Walters BC, Wilberger J, Surgical Management of Traumatic Brain
Injury Author Group. Surgical management of posterior fossa mass
lesions. Neurosurgery 2006 Mar;58(3 Suppl):S2-47-S2-55. \[30
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16540745)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Posterior fossa mass lesions

#### GUIDELINE CATEGORY

Management\
Treatment

#### CLINICAL SPECIALTY

Emergency Medicine\
Neurological Surgery\
Neurology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To provide recommendations for management of patients with posterior
fossa mass lesions

#### TARGET POPULATION

Patients with posterior fossa mass lesions

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Computed tomography (CT) scan

2.  Glasgow Coma Scale score

3.  Neurological monitoring

4.  Operative intervention (suboccipital craniectomy)

5.  Nonsurgical management

6.  Timing of surgery

#### MAJOR OUTCOMES CONSIDERED

-   Mortality rate

-   Glasgow outcome score

-   Functional recovery

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

A MEDLINE computer search using the following key words: \"posterior
fossa\" or \"cerebellum\" or \"cerebellar\" or \"occipital\" and
\"subdural\" or \"epidural\" or \"extradural\" or \"intradural\" or
\"parenchymal\" or \"intraparenchymal\" or \"intracerebellar\" or
\"fracture\" between 1975 and 2001 was performed. A total of 1828
documents were found. The search was narrowed to include the key words:
\"surgery\" or \"operative\" or \"craniotomy\" or \"craniectomy\" or
\"decompressive craniectomy\" or \"repair\" and \"trauma\" or
\"traumatic\" or \"TBI\" or \"CHI.\" A total of 430 articles were found.
A tertiary search adding the key words \"contusion,\" \"hemorrhagic
contusion,\" \"surgical decompression,\" \"craniostomy,\" \"TICH,\" and
\"DTICH\" was performed, yielding 421 articles. The secondary and
tertiary searches were combined, yielding a total of 433 articles. In
addition, the reference lists of selected articles were reviewed, and 24
articles were selected for critical analysis.

Papers primarily addressing the following topics were not included:
nontraumatic lesions, patients with associated posterior fossa anomalies
(e.g., Chiari malformation), posttraumatic aneurysms, chronic subdural
hematomas, vertebral artery dissection, patients undergoing
anticoagulation therapy, patients with associated illnesses (e.g.,
acquired immunodeficiency syndrome, idiopathic thrombocytopenia purpura,
hemophilia, arteriovenous malformation, after craniotomy, or von
Willebrand\'s disease), pre-computed tomography (CT) era reports, and
book chapters. In general, papers with the following characteristics
were also excluded: case series with less than 10 patients evaluated by
CT scan and with incomplete outcome data (mortality or Glasgow outcome
score \[GOS\]), case reports, and operative series with operations
occurring longer than 14 days from injury. Several articles with case
series of less than 10 patients were examined and reviewed because of
the limited number of patient series evaluating primary traumatic
posterior fossa mass lesions that exist in the literature. Selected
articles were evaluated for design, prognostic significance, therapeutic
efficacy, and overall outcome. In addition, several articles were
reviewed for the purposes of historical perspective.

#### NUMBER OF SOURCE DOCUMENTS

24

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Classification of Evidence**

When assessing the value of therapies or interventions, the available
data was classified into one of the following three categories according
to the following criteria:

**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

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

**Evaluation and Weighting of the Evidence**

The journal articles found have been carefully read and evaluated,
including an assessment of the methodology used in the studies. This not
only includes the establishment of the clinical question addressed
(e.g., therapeutic effectiveness, diagnostic tests, prognostic studies,
etc.) and type of study (randomized controlled trial, case-control
study, case series, etc.), but also the quality of the study with
respect to potential errors in design, execution, or conclusions
reached. Therefore, studies that might, on the surface, represent
evidence supporting one level of recommendation, may instead be flawed
enough to be devalued to support a recommendation of lesser strength.
The quality of the literature was evaluated in this way according to
well-established criteria. All articles were cross-reviewed and
disagreements were resolved by consensus.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

**Link Between Evidence and Guidelines**

The general concept of relating strength of recommendations to strength
of evidence reflecting varying degrees of clinical certainty was
formalized into a scheme that has been followed by medical societies,
including organized neurosurgery, from the inception of the *Guideline*
development process. Despite problems with the strict application of
this paradigm (some of which are displayed and discussed in this
supplement), the scheme has the benefit of using scientific evidence
rather than expert opinion for the substrate of the recommendations,
although expert opinion is used to formulate the recommendations
themselves, as well as to make judgments regarding the quality of the
evidence. The evidence-based scheme used in these and all *Guidelines*
regarding therapeutic effectiveness endorsed by the American Association
of Neurological Surgeons and the Congress of Neurological Surgeons
begins with classification of the literature into three categories of
evidence (see \"Rating Scheme for the Strength of the Evidence\" above).

The classification of evidence into these three categories leads to the
formulation of recommendations called *Standards*, *Guidelines*, and
*Options*. *Class I* evidence is used to support treatment
recommendations of the strongest type, practice *Standards*, reflecting
a *high degree of clinical certainty*. *Class II* evidence is used to
support *Guidelines*, reflecting a *moderate degree of clinical
certainty*. *Class III* evidence supports practice *Options* reflecting
*unclear clinical certainty*. This terminology was developed to
indicate, in normal vocabulary, the strength of the recommendations on
the basis of strong to weak medical evidence. In neurosurgery, this
scheme has been used to formulate *Guidelines*, rather than a scheme
that uses letters or numbers that have no grounding in language and are,
therefore, more easily misinterpreted. The link between scientific
evidence and recommendations has been highlighted in these *Guidelines*
by presenting those studies in the scientific foundation that support
the stated recommendation in boldface type.

**Expert Judgment and Empirical Evidence**

There are two ways in which expert judgment comes into *Guideline*
development. The most common use of expert opinion is in developing
recommendations for practice. This has been a usual method in the past
(as well as the present, in the form of textbook chapters), but has more
recently given way to more formalized approaches embraced by
evidence-based medicine methodology, such as that used in this
supplement. However, even in evidence-based methodology, expert opinion
is used to evaluate the literature as well as to frame the concepts and
wording of the recommendations. In addition, if the evidence is weak and
conflicting, expert opinion is used to derive recommendations. This use
is unavoidable, but the expert opinion is guided by the evidence
published in the literature, rather than from personal experience alone.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Levels of Recommendations**

**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*.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

In all Guidelines published under the auspices of the Brain Trauma
Foundation and the American Association of Neurological Surgeons, other
professional organizations were involved in either developing the
Guidelines or reviewed and approved them. In these Surgical Management
of Traumatic Brain Injury Guidelines, however, only neurosurgeons were
involved. These neurosurgeons represent a wide range of organizations.
There were representatives from the American Association of Neurological
Surgeons, the Congress of Neurological Surgeons, the European Brain
Injury Consortium, the American College of Surgeons (Committee of
Trauma) and the World Federation of Neurological Surgeons (Neurotrauma
section) involved in the development of these Surgical Management of
Traumatic Brain Injury Guidelines.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

\"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]{.underline}**

**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]{.underline}**

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]{.underline}**:

**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

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

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)

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate surgical management of posterior fossa mass lesions to
improve clinical outcomes and reduce morbidity and mortality

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

As in all other areas of evidence-based medicine, these Guidelines have
been formulated strictly in accordance with externally imposed
constraints. Only clinical human-based literature has been reviewed.
Only literature from 1975 through 2001 has been reviewed. Mainly
literature in English, with far fewer articles in other languages, was
reviewed. For these reasons, the reader must clearly understand that the
scope and level of magnitude of the recommendations made here are
distilled from the available literature and interpreted according to the
rules of evidence-based medicine.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, Servadei
F, Walters BC, Wilberger J, Surgical Management of Traumatic Brain
Injury Author Group. Surgical management of posterior fossa mass
lesions. Neurosurgery 2006 Mar;58(3 Suppl):S2-47-S2-55. \[30
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16540745)

#### ADAPTATION

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

#### DATE RELEASED

2006 Mar

#### GUIDELINE DEVELOPER(S)

Brain Trauma Foundation - Disease Specific Society

#### SOURCE(S) OF FUNDING

Brain Trauma Foundation\
Integra NeuroSciences

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*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

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### ENDORSER(S)

Congress of Neurological Surgeons - Professional Association

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format from the [Brain
Trauma Foundation Web
site](http://www2.braintrauma.org/guidelines/downloads/btf_surgical_guidelines_article.pdf).

Print copies: Available from Jamshid Ghajar, MD, PhD, Brain Trauma
Foundation, 708 Third Avenue, Suite 1810, New York, NY 10017, Email:
<ghajar@braintrauma.org>

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Introduction. Neurosurgery 2006 Mar;58(3 Suppl):S2-1-S2-3.

-   Methodology. Neurosurgery 2006 Mar;58(3 Suppl):S2-4-S2-6.

Electronic copies: Available in Portable Document Format (PDF) from the
[Brain Trauma Foundation Web
site](http://www2.braintrauma.org/guidelines/downloads/btf_surgical_guidelines_article.pdf).

Print copies: Available from Jamshid Ghajar, MD, PhD, Brain Trauma
Foundation, 708 Third Avenue, Suite 1810, New York, NY 10017, Email:
<ghajar@braintrauma.org>

#### PATIENT RESOURCES

None available

#### NGC STATUS

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

#### COPYRIGHT STATEMENT

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.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008