What is the treatment for a cerebellar infarction?

Treatment of Cerebellar Infarction

All patients with cerebellar infarction require immediate admission to an intensive care or stroke unit with early neurosurgical consultation, and decompressive suboccipital craniectomy should be performed urgently in those who develop neurological deterioration from brainstem compression or obstructive hydrocephalus. 1, 2

Immediate Triage and Initial Management

Admit every patient with cerebellar infarction to an intensive care or stroke unit, even if clinically stable on presentation, as deterioration typically occurs between days 2-4 after stroke onset, with peak risk on day 3. 1, 2, 3 The clinical presentation can be deceptively benign initially, only to rapidly progress to life-threatening brainstem compression. 4, 5

Early Neurosurgical Consultation

• Obtain neurosurgical consultation immediately upon diagnosis, not after deterioration begins, to facilitate rapid surgical intervention if needed. 1, 2
• If your facility lacks neurosurgical capabilities or comprehensive stroke care, transfer the patient urgently to a higher-level center. 1

Intensive Monitoring Protocol

Monitor continuously for up to 5 days for signs of clinical deterioration, which manifests as: 1, 2

• Depression of consciousness level (Glasgow Coma Scale <12 or decline ≥2 points)
• Brainstem compression signs: pupillary anisocoria, pinpoint pupils, loss of oculocephalic responses
• Cardiorespiratory changes: bradycardia, irregular breathing patterns, sudden apnea
• Radiographic deterioration: fourth ventricular compression, obstructive hydrocephalus, brainstem displacement 1, 2

Medical Management

Supportive Care Measures

• Elevate head of bed 0-30 degrees during periods of increased intracranial pressure. 1
• Maintain normoxia and correct hypovolemia with isotonic fluids. 1, 2
• Keep patient NPO (nothing by mouth) initially. 1, 2
• Treat hyperthermia aggressively and maintain glucose <8 mmol/L. 1, 2
• Initiate thromboembolic prophylaxis with subcutaneous low-dose heparin or low molecular weight heparin. 2

Osmotic Therapy for Deterioration

If clinical deterioration occurs, osmotic therapy with mannitol or hypertonic saline is reasonable as a temporizing measure while preparing for surgery. 1 However, this should not delay definitive surgical intervention.

Therapies to AVOID

Do not use hypothermia, barbiturates, or corticosteroids for cerebellar infarction with swelling—these lack evidence of benefit and are not recommended. 1, 2 This is a critical pitfall, as these agents are sometimes reflexively used in other forms of brain edema.

Surgical Management Algorithm

Indications for Surgery

Perform decompressive suboccipital craniectomy with dural expansion in patients who develop neurological deterioration from brainstem compression, regardless of whether they are awake, somnolent, or even comatose. 2, 6 Even comatose patients have a 38% chance of good recovery with timely decompressive surgery. 6

Surgical Approach Based on Clinical Scenario

For obstructive hydrocephalus:

• Emergency ventriculostomy is a reasonable first step if hydrocephalus is the predominant feature. 2
• However, ventriculostomy should be accompanied by decompressive suboccipital craniectomy to prevent upward cerebellar displacement and herniation. 2
• If ventriculostomy alone fails to improve neurological function, proceed immediately to decompressive craniectomy. 2

For brainstem compression without hydrocephalus:

• Proceed directly to decompressive suboccipital craniectomy with dural expansion as the primary intervention. 2, 6

Timing of Surgery

Do not delay surgery once deterioration begins—clinical deterioration to coma typically occurs within 24 hours of onset of symptoms. 6 The level of consciousness is the most powerful predictor of outcome, and waiting for further deterioration significantly worsens prognosis. 3

Prognostic Counseling

Inform families that functional outcomes after cerebellar infarction can be good following suboccipital craniectomy, with most patients achieving acceptable functional recovery. 2, 6 This is important for shared decision-making, as the surgery can be life-saving with meaningful neurological recovery even in severely affected patients.

Critical Pitfalls to Avoid

• Do not perform ventriculostomy alone without planning for potential craniectomy—this can precipitate upward herniation if significant mass effect develops. 2
• Do not wait for radiographic criteria alone to guide surgery—clinical deterioration should prompt immediate surgical intervention. 1, 2
• Do not withhold antiplatelet therapy indefinitely—if craniectomy is ruled out, initiate aspirin 100-300 mg for secondary stroke prevention. 1
• Do not assume initial clinical stability means low risk—deterioration can occur suddenly even after days of apparent stability. 4, 5, 3