Management of Cerebellar Infarct
Patients with cerebellar infarcts require immediate transfer to an intensive care or stroke unit with neuromonitoring capabilities and early neurosurgical consultation to facilitate planning of decompressive surgery or ventriculostomy if the patient deteriorates. 1
Initial Triage and Assessment
- Immediate neurosurgical consultation is essential due to the high risk of deterioration from edema and potential brainstem compression 1, 2
- Transfer to a center with higher level of care if comprehensive care and timely neurosurgical intervention are not available locally 1
- A multidisciplinary approach involving neurointensivists, vascular neurologists, and neurosurgeons is required 1
Neuroimaging and Monitoring
Critical imaging findings to monitor:
- Hypodensity >2/3 of cerebellar hemisphere
- Compression or displacement of 4th ventricle
- Obstructive hydrocephalus (30-40% incidence)
- Brainstem displacement/compression
- Compression of basal cisterns
- Hemorrhagic transformation 2
Serial CT scans are recommended to identify patients at high risk for developing symptomatic swelling 1
Clinical Monitoring for Deterioration
- Frequently monitor level of arousal and new brainstem signs 1
- Watch for:
Medical Management
General Supportive Care
- Maintain euvolemia
- 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)
- Implement thromboembolic prophylaxis 2
Management of Cerebral Edema
- Elevate head of bed to 30° 1
- Osmotic therapy is reasonable for patients with clinical deterioration from cerebral swelling 1
- Options include:
- Mannitol (1 g/kg of 20%)
- Hypertonic saline (various concentrations: 3%, 7.5%, 23.4%)
- Options include:
- Note: Hypothermia, barbiturates, and corticosteroids are not recommended due to insufficient data 1
Surgical Interventions
Indications for Surgical Intervention
- Neurological deterioration from brainstem compression
- Obstructive hydrocephalus
- Fourth ventricular compression
- Significant mass effect
Surgical Options
- Ventriculostomy for obstructive hydrocephalus (80-90% success rate) 2
- Decompressive suboccipital craniectomy with dural expansion for patients with neurological deterioration from brainstem compression (70-80% success rate) 2
Prognosis and Outcomes
- Without appropriate intervention, brainstem compression can be life-threatening with 50-60% mortality rate 2
- Surgical intervention after cerebellar infarct leads to acceptable functional outcomes in most patients (50-60% good outcome rate) 2
- Advanced age and additional brainstem infarction are predictors for poor outcome 3
Rehabilitation Considerations
- Implement comprehensive neurorehabilitation approach including:
- Physical therapy for mobility and strengthening
- Occupational therapy for activities of daily living
- Speech-language pathology for communication deficits and swallowing disorders
- Psychological interventions for anxiety, depression, and adjustment to disability 2
Common Pitfalls to Avoid
- Misdiagnosis: Cerebellar infarcts often present with non-specific symptoms (vertigo, nausea, vomiting, unsteady gait, headache) that can be mistaken for benign conditions like viral gastroenteritis or labyrinthitis 4, 5
- Delayed recognition of deterioration: Space-occupying edema can develop rapidly and lead to life-threatening complications
- Inadequate imaging: Early-stage posterior fossa ischemia is rarely seen with initial brain CT; MRI with diffusion-weighted imaging is more sensitive 2, 4
- Delayed surgical intervention: Timely escalation of treatment is crucial and should be guided by clinical and neuroradiological findings 3