What are the treatments for cerebellar stroke (cerebral vascular accident)?

From the Guidelines

Decompressive suboccipital craniectomy with dural expansion should be performed in patients with cerebellar infarction causing neurological deterioration from brainstem compression despite maximal medical therapy. This surgical intervention is indicated as a therapeutic approach in cases of neurological deterioration caused by cerebral edema as a result of cerebellar infarction that cannot be otherwise managed with medical therapy or ventriculostomy in the setting of obstructive hydrocephalus 1. The management of cerebellar stroke involves immediate medical intervention, which may include the administration of tissue plasminogen activator (tPA) for ischemic strokes, and surgical intervention for hemorrhagic strokes or those with significant mass effect.

Medical Management

Medical management of cerebellar stroke focuses on preventing further brain injury and managing complications. This includes:

• Control of blood pressure using medications like ACE inhibitors or ARBs
• Prevention of future clots with antiplatelet drugs such as aspirin (81-325mg daily) or clopidogrel (75mg daily), or anticoagulants like warfarin (with an INR target of 2-3) or direct oral anticoagulants such as apixaban (5mg twice daily) 1
• Management of intracranial pressure, which may involve measures to prevent further deterioration from tissue displacement and brain stem shift, including the restriction of free water, correction of factors that could exacerbate swelling (e.g., hypoxemia, hypercarbia, and hyperthermia), and elevation of the head of the bed to facilitate venous drainage.

Surgical Intervention

Surgical intervention, specifically decompressive suboccipital craniectomy, is considered for patients with cerebellar infarction who show signs of neurological deterioration due to brainstem compression, despite maximal medical therapy 1. This procedure aims to relieve pressure on the brainstem and prevent further neurological deterioration. The decision to proceed with surgery should be made promptly, considering the patient's overall clinical condition and the potential benefits and risks of the intervention.

Rehabilitation

Rehabilitation plays a crucial role in the recovery of patients who have suffered a cerebellar stroke. It includes:

• Physical therapy to improve balance and coordination
• Occupational therapy to assist with daily activities
• Speech therapy if there are communication difficulties The goal of rehabilitation is to help patients regain independence in their daily activities, focusing on the functions controlled by the cerebellum, such as coordination and balance. Recovery can take months, with significant improvements typically occurring in the first three to six months.

In making treatment decisions for cerebellar stroke, it is essential to prioritize interventions that improve morbidity, mortality, and quality of life, considering the most recent and highest quality evidence available 1.

From the Research

Treatments for Cerebellar Stroke

• The treatment of cerebellar stroke involves the identification and treatment of the underlying vascular lesions at an early stage to prevent subsequent occurrences of stroke and improve patients' outcomes 2.
• Systemic thrombolysis with alteplase is the only approved medical treatment for patients with acute ischaemic stroke, including cerebellar stroke 3.
• Thrombectomy is also increasingly used to treat proximal occlusions of the cerebral arteries, but has not shown superiority over systemic thrombolysis with alteplase 3.
• Anticoagulation may be indicated in patients with ischemic stroke caused by embolization from cervical artery dissection, catastrophic antiphospholipid antibodies syndrome (APS), and some cases of Covid 19 4.
• For secondary prevention, anticoagulation is recommended for Cardioembolic stroke such as nonvalvular atrial fibrillation and other cardiopathies, some patients with cervical artery dissection, stroke associated with cancer, and thrombophilia such as APS 4.

Thrombolysis and Thrombectomy

• Thrombolysis with alteplase is effective when administered to patients with potentially disabling stroke, who are not at high risk of bleeding, within 4.5 hours of the time the patient was last known to be well 5.
• Emerging evidence suggests that other thrombolytics such as tenecteplase may be even more effective 5.
• Endovascular thrombectomy (via angiography) effectively reduces risk of death or dependency in patients with large vessel occlusion (internal carotid, proximal middle cerebral and basilar arteries) if applied within 6 hours of the time they were last known to be well 5.
• Endovascular thrombectomy is also beneficial 6-24 hours from the last known well time in selected patients with favourable brain imaging 5.

Secondary Prevention

• Important developments in secondary stroke prevention include the use of direct oral anticoagulants or left atrial appendage occlusion for atrial fibrillation, and endovascular closure of patent foramen ovale 5.
• The timing to restart anticoagulation after a large ischemic stroke or after a cerebral hemorrhagic transformation always represents a challenge, and should be delayed at least two weeks, ideally after four weeks 4.