What is the treatment for a cerebellar infarct?

Treatment of Cerebellar Infarction

The treatment of cerebellar infarction requires close neurological monitoring in an intensive care or stroke unit with early neurosurgical consultation, as deterioration may occur rapidly and require emergent surgical intervention. 1

Initial Management

Monitoring and General Measures

• Close neurological and cardiovascular monitoring in an intermediate or intensive care stroke unit for up to 5 days, even if the patient initially appears stable 1
• Frequent monitoring for decreased level of arousal or new brainstem signs, which indicate deterioration 1
• Elevation of the head of the bed between 0-30° during periods of increased intracranial pressure 1
• Ensuring sufficient cerebral oxygenation 1
• Correction of hypovolemia with isotonic fluids (avoid hypotonic fluids) 1
• Prophylaxis and treatment of hyperthermia 1
• Treatment of hyperglycemia 1
• NPO status (avoid oral intake of food and fluids) initially 1

Medical Management

• Osmotic therapy (mannitol or hypertonic saline) is reasonable for patients with clinical deterioration from cerebral swelling 1
• Thromboembolic prophylaxis with subcutaneous low-dose heparin, low molecular weight heparin, or heparinoids 1
• Consider intermittent pneumatic compression and elastic stockings of lower limbs 1
• Treatment of headaches with paracetamol/acetaminophen (avoid NSAIDs and opioids) 1
• Treatment of nausea and vomiting 1
• Blood pressure management: maintain adequate cerebral perfusion pressure (>60 mmHg) 1
• Antiplatelet therapy (aspirin 100-300mg) if surgical intervention is unlikely; if craniectomy is likely, withhold antiplatelet agents 1

Surgical Management

Indications for Surgical Intervention

Surgical intervention is indicated for:

1. Neurological deterioration from brainstem compression despite maximal medical therapy 1
2. Obstructive hydrocephalus 1
3. Compression/displacement of the 4th ventricle 1
4. Displacement of the brainstem 1

Surgical Approach

The surgical management follows a stepwise algorithm:

1. Ventriculostomy (External Ventricular Drainage)

   • First-line surgical intervention for obstructive hydrocephalus 1
   • Reasonable first step in surgical management paradigm 1

2. Decompressive Suboccipital Craniectomy with Dural Expansion

   • Indicated when ventriculostomy fails to improve neurological function 1
   • Should be performed in patients with cerebellar infarction causing neurological deterioration from brainstem compression despite maximal medical therapy 1
   • When indicated, obstructive hydrocephalus should be treated concurrently with ventriculostomy 1

Prognostic Considerations

• Outcomes after cerebellar infarct can be good following suboccipital craniectomy 1
• Advanced brainstem dysfunction (such as locked-in syndrome) is a predictor of unfavorable outcome 1
• Radiological predictors of space-occupying edema include:
  • Hypodensity >2/3 of the cerebellar hemisphere 1
  • Compression/displacement of the 4th ventricle 1
  • Obstructive hydrocephalus 1
  • Displacement of the brainstem 1
  • Compression of the basal cisternae 1
  • Hemorrhagic transformation of the cerebellar infarction 1

Common Pitfalls and Caveats

1. Delayed Recognition: Cerebellar infarction may initially present with nonspecific symptoms like nausea, vomiting, and dizziness that mimic benign conditions, leading to delayed diagnosis and treatment 2

2. Rapid Deterioration: Due to the limited space in the posterior fossa, cerebellar infarcts can rapidly deteriorate, causing life-threatening brainstem compression or obstructive hydrocephalus 3

3. Surgical Timing: Delayed surgical intervention may cause additional and irreversible brain damage; therefore, early neurosurgical consultation is critical 1

4. Ineffective Medical Therapies: Corticosteroids, hypothermia, and barbiturates lack sufficient evidence in the setting of cerebellar swelling and are not recommended 1

5. Monitoring Duration: Even patients who appear stable initially should be monitored for at least 5 days, as deterioration can occur suddenly 1

By following this structured approach to the management of cerebellar infarction, focusing on early recognition, appropriate medical management, and timely surgical intervention when indicated, mortality and morbidity can be significantly reduced.