What is the management for a patient with a cerebellar subacute infarct?

Management of Cerebellar Subacute Infarct

For a patient with cerebellar subacute infarct, immediate admission to an intensive care or stroke unit with close neurological monitoring is essential, with early neurosurgical consultation to facilitate timely decompressive suboccipital craniectomy if neurological deterioration occurs from brainstem compression or obstructive hydrocephalus. 1

Initial Triage and Monitoring

Admit all patients with cerebellar infarction to an intensive care or stroke unit for comprehensive treatment and close monitoring, even if initially stable. 2 Patients with territorial cerebellar infarctions require monitoring for up to 5 days. 2

• Obtain early neurosurgical consultation to facilitate planning of potential decompressive surgery or ventriculostomy if the patient deteriorates. 1, 2
• If comprehensive care and timely neurosurgical intervention are not available locally, transfer to a higher level center is reasonable. 1

Critical Signs of Deterioration to Monitor

Watch closely for clinical deterioration manifesting as: 2

• Depression in consciousness level or Glasgow Coma Scale score <12 on admission, or decline of ≥2 points
• New brainstem signs: pupillary anisocoria, pinpoint pupils, loss of oculocephalic responses, bradycardia, irregular breathing patterns, sudden apnea
• Radiographic deterioration: fourth ventricular compression and evidence of hydrocephalus

Medical Management

Supportive Care Measures

• Elevate the upper body between 0° and 30° to help manage intracranial pressure. 2
• Ensure sufficient cerebral oxygenation and correct hypovolemia with isotonic fluids. 2
• Avoid oral intake of food and fluids initially. 2
• Treat hyperthermia and maintain normoglycemia (glucose <8 mmol/L). 2
• Initiate thromboembolic prophylaxis with subcutaneous low-dose heparin, low molecular weight heparin, or heparinoids. 2

Osmotic Therapy

Osmotic therapy with mannitol or hypertonic saline is reasonable for patients with clinical deterioration from cerebral swelling. 2 However, this is a temporizing measure while preparing for definitive surgical intervention if needed.

Surgical Management Algorithm

For Obstructive Hydrocephalus

If the patient develops symptoms of obstructive hydrocephalus, emergency ventriculostomy is a reasonable first step in the surgical management paradigm. 1 However, there is a critical caveat: ventriculostomy alone carries a risk of upward herniation, which can be minimized with conservative cerebrospinal fluid drainage. 1

• If cerebrospinal diversion by ventriculostomy fails to improve neurological function, decompressive suboccipital craniectomy should be performed. 1
• When ventriculostomy is needed, it should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement. 2

For Neurological Deterioration from Mass Effect

Decompressive suboccipital craniectomy with dural expansion should be performed in patients with cerebellar infarction causing neurological deterioration from brainstem compression despite maximal medical therapy. 1 This is a Class I, Level B-NR recommendation. 1

• When deemed safe and indicated, obstructive hydrocephalus should be treated concurrently with ventriculostomy. 1
• The data strongly support decompressive cerebellar craniectomy for the management of acute ischemic cerebellar stroke with mass effect. 1

Prognostic Counseling

When considering decompressive suboccipital craniectomy for cerebellar infarction, it may be reasonable to inform family members that the outcome after cerebellar infarct can be good after suboccipital craniectomy. 1 Surgery after cerebellar infarct leads to acceptable functional outcomes in most patients. 2

Common Pitfalls to Avoid

• Do not use hypothermia, barbiturates, or corticosteroids for ischemic cerebellar swelling, as they lack sufficient evidence. 2
• Do not perform ventriculostomy alone without planning for potential decompressive craniectomy, as this can lead to upward herniation if significant edema or mass effect develops. 1
• Do not delay neurosurgical consultation until deterioration occurs; early involvement is essential for optimal outcomes. 1, 2

Shared Decision-Making

Discussion of care options and possible outcomes should take place quickly with patients (if possible) and caregivers. 1 Medical professionals should ascertain and include patient-centered preferences in shared decision making, especially during prognosis formation and when considering interventions or limitations in care. 1