What is the management of cerebellar infarction?

Management of Cerebellar Infarction

The management of cerebellar infarction requires close neurological monitoring and early surgical intervention with decompressive suboccipital craniectomy with dural expansion for patients who show signs of neurological deterioration from brainstem compression despite maximal medical therapy. 1

Initial Assessment and Monitoring

• Close neurological monitoring is essential for all patients with cerebellar infarction due to high risk of deterioration

  • Monitor level of arousal and new brainstem signs frequently (Class I; Level of Evidence C) 1
  • Watch for signs of deterioration: pupillary anisocoria, pinpoint pupils, loss of oculocephalic responses, bradycardia, irregular breathing patterns 1
  • Critical clinical signs of deterioration include:
    • Depression in level of consciousness
    • Glasgow Coma Scale score <12 on admission
    • Glasgow Coma Scale score decline of ≥2 points 1

• Imaging assessment for critical findings:

  • Hypodensity >2/3 of cerebellar hemisphere
  • Compression or displacement of 4th ventricle
  • Obstructive hydrocephalus
  • Brainstem displacement/compression
  • Compression of basal cisterns 2

Medical Management

1. Initial medical measures:

   • Elevate head of bed to 30° 1
   • Control blood pressure:
     • Non-thrombolysed patients: Systolic BP <220 mmHg, Diastolic BP <120 mmHg
     • Thrombolysed patients: Systolic BP <185 mmHg, Diastolic BP <110 mmHg 2
   • Treat hyperthermia aggressively (temperature >37.5°C)
   • Control hyperglycemia (avoid glucose >180 mg/dL)
   • Maintain euvolemia 2

2. Osmotic therapy for patients with clinical deterioration from cerebral swelling is reasonable (Class IIa; Level of Evidence C) 1

   • Options include mannitol and hypertonic saline with varying concentrations (3%, 7.5%, 23%)
   • Note: Hypothermia, barbiturates, and corticosteroids are not recommended due to insufficient data (Class III; Level of Evidence C) 1

3. Thromboembolic prophylaxis:

   • Subcutaneous heparin or low-molecular-weight heparin
   • Consider intermittent pneumatic compression and elastic stockings 2

Surgical Management

1. Ventriculostomy:

   • First-line surgical intervention for acute obstructive hydrocephalus 1
   • Success rate of 80-90% 2
   • Should be performed when there is radiographic evidence of hydrocephalus and clinical deterioration 1

2. Decompressive suboccipital craniectomy with dural expansion:

   • Should be performed in patients with neurological deterioration from brainstem compression despite maximal medical therapy (Class I; Level of Evidence B-NR) 1
   • When ventriculostomy fails to improve neurological function, proceed to decompressive craniectomy 1
   • Success rate of 70-80% 2
   • Caution: Ventriculostomy alone carries risk of upward herniation; should be combined with decompressive craniectomy when significant edema or mass effect is present 1

3. Surgical timing:

   • Deterioration typically starts around day 3 post-stroke, with rapid progression to coma within 24 hours 3
   • Early transfer to an institution with neurosurgical expertise should be considered for patients at risk for malignant brain edema 1

Prognosis and Outcomes

• Surgery after cerebellar infarct leads to acceptable functional outcomes in most patients, with 50-60% good outcome rate 2
• Without appropriate intervention, brainstem compression can be life-threatening, with 50-80% mortality rate 2, 3
• Even comatose patients have a 38% chance of good recovery with decompressive surgery 3
• Poor prognostic factors include:
  • Age >60 years
  • Initial brainstem signs
  • Late clinical stage at time of intervention 3

Decision Algorithm for Management

1. For stable patients with cerebellar infarction:

   • Close neurological monitoring
   • Medical management as outlined above

2. For patients with worsening level of consciousness and radiologically evident ventricular enlargement:

   • Immediate ventriculostomy 4

3. For patients with any of the following:

   • Clinical status worsening despite ventriculostomy
   • Worsening accompanied by signs of brainstem compression
   • Tight posterior fossa
   • Proceed to decompressive suboccipital craniectomy with dural expansion 4

4. When considering decompressive surgery:

   • Inform family members that outcomes after cerebellar infarct can be good after suboccipital craniectomy (Class IIb; Level of Evidence C-LD) 1
   • Include patient-centered preferences in shared decision making 1

The management of cerebellar infarction requires vigilant monitoring and decisive action. Early recognition of deterioration and prompt surgical intervention when indicated are critical for reducing mortality and improving functional outcomes.