How to manage a mature cerebellar infarction?

From the Guidelines

Management of a mature cerebellar infarction should prioritize prevention of complications, support of recovery, and reduction of future stroke risk, with a key consideration being the potential need for decompressive suboccipital craniectomy in cases of neurological deterioration due to brainstem compression or obstructive hydrocephalus, as recommended by the 2018 guidelines for the early management of patients with acute ischemic stroke 1. The initial approach to managing a mature cerebellar infarction includes:

• Antiplatelet therapy with aspirin 81-325 mg daily or clopidogrel 75 mg daily for secondary stroke prevention
• Blood pressure management to target levels below 140/90 mmHg using appropriate antihypertensives such as ACE inhibitors, ARBs, or calcium channel blockers
• Statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) regardless of baseline cholesterol levels to reduce recurrent stroke risk Close monitoring for cerebellar edema is essential, particularly in the first 72 hours, as deterioration may necessitate neurosurgical intervention such as suboccipital decompression, which has been shown to be effective in preventing and treating herniation and brain stem compression in patients with cerebellar infarction 1. Rehabilitation should begin as soon as the patient is medically stable, focusing on:
• Balance, coordination, and gait training with physical therapy 3-5 times weekly
• Occupational therapy for activities of daily living
• Speech therapy if dysarthria is present Ataxia may be managed with targeted exercises and occasionally medications like propranolol (10-40 mg twice daily) or primidone (50-250 mg daily) for severe tremor. Lifestyle modifications including smoking cessation, limited alcohol intake, regular exercise, and a Mediterranean or DASH diet are important components of long-term management. Regular follow-up with neurology is recommended every 3-6 months initially, then annually. In cases where decompressive suboccipital craniectomy is considered, it is crucial to inform family members that the outcome after cerebellar infarct can be good after sub-occipital craniectomy, as noted in the 2018 guidelines 1.

From the Research

Management of Mature Cerebellar Infarction

• The management of mature cerebellar infarction involves both medical and surgical interventions, with the goal of preventing further brain damage and improving patient outcomes 2, 3, 4, 5, 6.
• Surgical intervention, such as ventricular drainage or decompressive craniotomy, may be necessary in patients with cerebellar infarction if mass effect develops, especially in those with signs of brainstem compression or hydrocephalus 2, 3, 4, 6.
• The level of consciousness is a powerful predictor of outcome in patients with cerebellar infarction, with deterioration of consciousness typically occurring between days 2 and 4 after admission 2.
• Treatment strategies for space-occupying edema include pharmacological antiedema and intracranial pressure-lowering therapies, ventricular drainage, and suboccipital decompressive surgery, with or without resection of necrotic tissue 4, 5, 6.
• Patients with large cerebellar infarcts should be treated and monitored in an experienced stroke unit or (neuro)intensive care unit, with timely escalation of treatment guided by clinical and neuroradiological rationales 5.
• The outcome in survivors of space-occupying cerebellar stroke is not always good, with advanced age and additional brainstem infarction being predictors of poor outcome 5.

Surgical Interventions

• Decompressive suboccipital craniectomy may be an effective, lifesaving procedure for malignant cerebellar edema after a large infarction 4.
• External ventricular drainage alone or followed by suboccipital craniectomy may be recommended for patients with worsening levels of consciousness and radiologically evident ventricular enlargement 6.
• Surgical resection of necrotic tissue may be reserved for patients whose clinical status worsens despite ventriculostomy, those for whom worsening is accompanied by signs of brainstem compression, and those with tight posterior fossae 6.

Medical Management

• The general treatment of ischemic cerebellar infarction does not differ from that of supratentorial ischemic strokes, with pharmacological antiedema and intracranial pressure-lowering therapies being used to manage space-occupying edema 5.
• Close monitoring and supervision are necessary to recognize life-threatening exacerbations, such as rapid deterioration in consciousness, which should be considered a sign of increasing intracranial pressure progressing with the development of hydrocephalus internus occlusus 3.