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
Monitoring and Recognition of Deterioration
- Clinicians should frequently monitor for level of arousal or new brainstem signs in patients with cerebellar stroke at high risk for deterioration 2
- Signs of deterioration include:
- Clinical signs of brainstem compression with neurological deterioration
- Obstructive hydrocephalus
- Depression in level of consciousness
- Glasgow Coma Scale score <12 on admission or decline of ≥2 points 2
- Development of pupillary anisocoria, pinpoint pupils, and loss of oculocephalic responses 2
- Bradycardia, irregular breathing patterns, and sudden apnea (indicating severe brainstem compression) 2
Acute Medical Management
- Elevate the head of bed to 30° to reduce intracranial pressure 2, 1
- Osmotic therapy is reasonable for patients with clinical deterioration from cerebral swelling 2, 1
- Options include mannitol and hypertonic saline with varying concentrations (3%, 7.5%, 23%) 2
- Blood pressure management:
- Treat hyperthermia aggressively (temperature >37.5°C) 1
- Control hyperglycemia (avoid glucose >180 mg/dL) 1
- Maintain euvolemia 1
- Implement thromboembolic prophylaxis with subcutaneous heparin or low-molecular-weight heparin 1
- Consider intermittent pneumatic compression and elastic stockings 1
Surgical Interventions
- Decompressive suboccipital craniectomy with dural expansion should be considered for patients with neurological deterioration from brainstem compression 1
- Success rate is reported at 70-80% 1
- Ventriculostomy may be considered for obstructive hydrocephalus 1
Important Considerations and Pitfalls
- Cerebellar infarction often presents with non-specific symptoms (nausea, vomiting, dizziness, unsteady gait) that can mimic benign conditions like viral gastroenteritis or labyrinthitis 3
- Early-stage posterior fossa ischemia is rarely visible on initial brain CT scans, potentially leading to misdiagnosis 4
- Space-occupying edema is a frequent and potentially life-threatening complication due to the tight posterior fossa providing little compensating space 5
- Contrary to common belief that outcomes in survivors are usually good, recent studies suggest many patients have poor long-term outcomes, particularly those with advanced age and additional brainstem infarction 5
- Hypothermia, barbiturates, and corticosteroids are not recommended due to insufficient data 2, 1
Rehabilitation Management
- A multipronged approach to neurorehabilitation is strongly recommended for patients with large volume brain compromise 1
- Components include:
- Physical therapy for pain management, range of motion, strengthening, and functional mobility 1
- Occupational therapy for activities of daily living and adaptive equipment needs 1
- Speech-language pathology for communication deficits and swallowing disorders 1
- Psychological interventions for anxiety, depression, and adjustment to disability 1
- Early mobility and multimodal sensory stimulation should be initiated as soon as the patient can tolerate it 6
- Ensure continuity of care between settings for optimal outcomes 1
The management of cerebellar infarction requires prompt recognition, close monitoring, and a coordinated approach between neurointensive care physicians, neurologists, and neurosurgeons to prevent potentially fatal complications and optimize functional recovery 5.