What is the treatment for cerebellar strokes?

From the Guidelines

Treatment for cerebellar strokes should prioritize immediate medical intervention, including stabilizing vital signs, managing intracranial pressure, and preventing complications, with surgical decompression through suboccipital craniectomy considered for large cerebellar infarctions causing significant swelling or hemorrhagic strokes with mass effect, as recommended by the most recent guidelines 1.

Key Considerations

• For ischemic cerebellar strokes, tissue plasminogen activator (tPA) may be administered within 4.5 hours of symptom onset to dissolve the clot.
• Surgical decompression through suboccipital craniectomy is recommended for patients with cerebellar infarction causing neurological deterioration from brainstem compression despite maximal medical therapy, as stated in the 2018 guidelines 1.
• Rehabilitation is crucial after the acute phase and includes physical therapy to improve balance, coordination, and gait; occupational therapy for daily activities; and speech therapy if speech is affected.
• Medications typically include antiplatelets like aspirin (81-325 mg daily) or clopidogrel (75 mg daily) for secondary prevention, along with management of underlying risk factors such as hypertension, diabetes, and hyperlipidemia.

Management of Cerebellar Infarction

• The 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage recommends urgent surgical hematoma evacuation with or without external ventricular drain (EVD) for patients with cerebellar intracerebral hemorrhage (ICH) who are deteriorating neurologically, have brainstem compression and/or hydrocephalus from ventricular obstruction, or have cerebellar ICH volume ≥15 mL 1.
• The 2014 recommendations for the management of cerebral and cerebellar infarction with swelling suggest that suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically due to swollen cerebellar stroke 1.

Outcome and Prognosis

• Recovery from cerebellar strokes can be significant due to the brain's neuroplasticity, though some patients may experience persistent symptoms like ataxia, dizziness, or coordination problems requiring long-term rehabilitation.
• The outcome after cerebellar infarct can be good after sub-occipital craniectomy, as stated in the 2018 guidelines 1.

From the Research

Treatment Overview

The treatment for cerebellar strokes involves a range of strategies, including:

• Pharmacological interventions, such as antiplatelet or anticoagulant treatments, to reduce the risk of recurrence and pulmonary embolism 2
• Thrombolytic therapy, which can reduce the frequency and severity of complications, but carries a high immediate risk of aggravation or death by haemorrhagic transformation 2
• Surgical intervention, such as decompressive craniectomy, for space-occupying cerebellar infarctions or hemorrhages 3, 4, 5
• Management of cerebrovascular risk factors, including aggressive treatment with drugs and lifestyle interventions, and short-term dual anti-platelet therapy for secondary prevention 5

Acute Management

In the acute phase of cerebellar stroke, the management often requires difficult and prompt decisions by treating neurologists, and certain easily identifiable clinical and imaging findings may assist in appropriate patient triage and timely neurosurgical intervention 3. The use of aspirin has a positive risk-benefit balance, preventing about 5 deaths per 1000 patients with ischemic stroke, and should be given as soon as computed tomography has ruled out intracerebral hemorrhage 2.

Surgical Intervention

Surgical intervention, such as suboccipital decompressive surgery, with or without resection of necrotic tissue, may be necessary for space-occupying cerebellar infarctions or hemorrhages 4. The decision to perform surgical intervention should be guided by clinical and neuroradiological rationales, and should be carried out in close cooperation among neurointensive care physicians, neurologists, and neurosurgeons 4.

Secondary Prevention

Secondary prevention of posterior circulation strokes, including cerebellar strokes, involves aggressive treatment of cerebrovascular risk factors with both drugs and lifestyle interventions, and short-term dual anti-platelet therapy 5. Randomized controlled trial data suggest that basilar artery stenosis is better treated with medical therapy than stenting, which has a high peri-procedural risk 5.