What is the initial management for a cerebrovascular accident (CVA) presenting with cerebellar symptoms?

Initial Management of Cerebellar Stroke

For a cerebrovascular accident presenting with cerebellar symptoms, the initial management should focus on close neurological monitoring in an intensive care or stroke unit with immediate neurosurgical consultation, as suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically. 1

Recognition and Monitoring

• Patients with cerebellar infarction should be closely monitored for level of arousal or new brainstem signs, which indicate deterioration 1
• Clinical deterioration in cerebellar infarcts manifests as brainstem compression, depression in consciousness level, Glasgow Coma Scale score <12 on admission, or a decline of ≥2 points 1
• Radiographic deterioration appears as fourth ventricular compression and evidence of hydrocephalus 1
• Patients with territorial cerebellar infarctions require monitoring for up to 5 days, even if initially stable 1

Initial Medical Management

• Transfer to an intensive care or stroke unit is essential for comprehensive treatment and close monitoring 1
• Elevate the upper part of the body between 0° and 30° to help manage intracranial pressure 1
• Ensure sufficient cerebral oxygenation and correct hypovolemia with isotonic fluids 1
• Avoid oral intake of food and fluids initially 1
• Treat hyperthermia and maintain normoglycemia (glucose <8 mmol/L) 1
• 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 should be initiated 1

Surgical Management

• Neurosurgical consultation should be sought early to facilitate planning of potential decompressive surgery 1
• In patients with cerebellar stroke who deteriorate neurologically, suboccipital craniectomy with dural expansion should be performed 1
• If ventriculostomy is needed to relieve obstructive hydrocephalus, it should be accompanied by decompressive suboccipital craniectomy to avoid upward cerebellar displacement 1
• Surgery after cerebellar infarct leads to acceptable functional outcomes in most patients 1

Pitfalls and Caveats

• Cerebellar infarction is frequently misdiagnosed (34% of cases), often mistaken for peripheral vestibulopathy, particularly when presenting with nausea, vomiting, and absence of obvious neurological signs 2
• The case fatality rate for cerebellar infarction (23%) is higher than for other brain infarct locations, making prompt recognition critical 3
• Patients with mild symptoms (NIHSS ≤4) tend to present late to emergency departments (>4.5 hours), potentially missing the window for acute interventions 2
• Hypothermia, barbiturates, and corticosteroids lack sufficient evidence in the setting of ischemic cerebellar swelling and are not recommended 1
• Cerebellar infarcts can present with isolated vertigo or hearing loss without other neurological symptoms, leading to delayed diagnosis 4, 5

Monitoring for Complications

• Monitor for signs of brainstem compression: pupillary anisocoria, pinpoint pupils, loss of oculocephalic responses, bradycardia, irregular breathing patterns, and sudden apnea 1
• Watch for development of obstructive hydrocephalus, which is a secondary manifestation in most instances of cerebellar swelling 1
• Survivors of cerebellar infarction have a high risk (22%) of subsequent brainstem infarction during follow-up, requiring vigilant secondary prevention 3

Outcome Considerations

• At 3 months, approximately 65% of patients with cerebellar infarction achieve functional independence (mRS 0-2) 2
• History of atrial fibrillation, hypertension, mixed cerebellar infarction (involving additional territories), and in-hospital stroke-related complications are associated with poor outcomes 2
• Clinicians may discuss with family members that the outcome after cerebellar infarct can be good after suboccipital craniectomy 1