What is the treatment for viral cerebellitis?

Treatment of Viral Cerebellitis

Viral cerebellitis typically requires only supportive care without specific antiviral treatment, as the disease is usually self-limiting and resolves within one to three weeks. 1

Primary Management Approach

No Antiviral Therapy Required

• Antiviral treatments are not normally used for viral cerebellitis because the primary pathogenic process is thought to be immune-mediated demyelination rather than direct viral cytopathology 1
• This applies specifically to VZV cerebellitis and other common viral causes of isolated cerebellar inflammation 1
• The self-limiting nature of the condition (resolving in 1-3 weeks) does not warrant antiviral intervention 1

Supportive Care

• Full supportive measures are the mainstay of treatment, with monitoring for complications 2
• Patients should be observed for signs of cerebellar swelling, hydrocephalus, or increased intracranial pressure 3, 4

Role of Corticosteroids

When to Consider Steroids

• Corticosteroids should be used in cases with marked cerebellar edema, brain shift, raised intracranial pressure, or hydrocephalus 3, 4
• Standard dexamethasone dosing can be effective for mild to moderate cases with cerebellar swelling 5
• High-dose corticosteroids (e.g., 60-80 mg prednisolone daily for 3-5 days) may be needed for more severe presentations 1
• One pediatric series showed corticosteroids were the most commonly used treatment (6 of 9 patients), with good outcomes 4

Evidence Supporting Steroid Use

• A case report demonstrated complete resolution of clinical and radiological signs within 1 week using standard dexamethasone treatment for acute cerebellitis with cerebellar swelling 5
• COVID-19-associated cerebellitis showed complete symptom resolution following corticosteroid treatment 6

Critical Distinction: Cerebellitis vs. Encephalitis

Do NOT Confuse with VZV Encephalitis

• VZV encephalitis (not cerebellitis) requires intravenous aciclovir 10-15 mg/kg three times daily for up to 14 days 1
• VZV encephalitis involves direct brain parenchymal infection with different pathophysiology than post-infectious cerebellitis 1
• If there is a vasculitic component or stroke-like presentation with VZV, both aciclovir and corticosteroids are indicated 1

Monitoring and Complications

Imaging Requirements

• MRI is the preferred imaging modality to diagnose cerebellitis, showing T2-weighted and FLAIR hyperintensities in cerebellar cortex (unilateral or bilateral) 3, 4
• CT may be normal or show only indirect signs like triventricular hydrocephalus from aqueductal compression 4
• Follow-up imaging may remain abnormal in 71% of adult cases despite clinical recovery 3

Red Flags Requiring Escalation

• Falling level of consciousness requires urgent ICU assessment for airway protection and management of raised intracranial pressure 1
• Development of hydrocephalus (occurred in 9 of 35 adult cases reviewed) may require neurosurgical intervention with external ventricular drain placement or decompressive surgery 3, 4
• Patients should have access to neurological specialist opinion within 24 hours 1

Common Pitfalls to Avoid

• Do not initiate aciclovir for isolated cerebellitis - this wastes resources and exposes patients to unnecessary renal toxicity risk 1
• Do not assume all cerebellar presentations are benign - approximately 26% of adult cases develop hydrocephalus requiring intervention 3
• Do not delay corticosteroids in patients with cerebellar swelling and mass effect - this is a medical and surgical emergency requiring high-dose steroids 4
• Do not miss the initial presentation - six adult patients initially presented with only headache and nausea before returning with cerebellar signs 3

Prognosis

• Uncomplicated cases can be successfully managed with supportive measures and have good prognosis 2
• However, 50% of adult cases may have neurological sequelae despite treatment 3
• Eight of nine pediatric patients in one series recovered completely with appropriate treatment 4