What is the appropriate management for a patient with acute cerebellar infarcts, dyslipidemia, normal MRA findings, and ataxia, presenting with headache and dizziness?

Management of Acute Cerebellar Infarcts with Ataxia

This patient requires immediate neurosurgical consultation and close neuromonitoring in an intensive care or stroke unit, as bilateral cerebellar infarcts carry significant risk for life-threatening deterioration from edema, brainstem compression, and hydrocephalus. 1

Immediate Triage and Monitoring

• Transfer to an intensive care or stroke unit with continuous neuromonitoring capabilities is mandatory for patients with bilateral cerebellar infarcts, even with preserved consciousness, as this represents a potential neurosurgical emergency 1, 2
• Urgent neurosurgical consultation should be obtained immediately to facilitate planning for potential decompressive suboccipital craniectomy, as deterioration can occur rapidly within 72-96 hours 2, 1
• Serial neurological examinations focusing on level of consciousness are critical, as decreased arousal is the most reliable indicator of dangerous tissue swelling and impending herniation 2

Critical Assessment for Surgical Intervention

• Monitor closely for signs of deterioration including drowsiness, worsening ataxia, new cranial nerve palsies, breathing irregularities, or cardiac dysrhythmias, which indicate brainstem compression requiring emergency surgery 2, 3
• Decompressive suboccipital craniectomy with dural expansion is lifesaving and should be performed emergently if consciousness declines, as this is more effective than medical management alone 2, 1
• A critical pitfall is performing ventriculostomy alone for hydrocephalus without decompressive craniectomy, which can cause fatal upward herniation 1

Acute Medical Management

Antithrombotic Therapy

• Aspirin 150-300 mg should be initiated within 48 hours after CT/MRI confirms ischemic stroke and excludes hemorrhage 2
• Routine anticoagulation with intravenous heparin is not recommended for unselected acute ischemic stroke patients 2
• Subcutaneous heparin or low-molecular-weight heparin for deep venous thrombosis prophylaxis should be started 2

Blood Pressure Management

• Maintain systolic BP <220 mmHg and diastolic <120 mmHg without aggressive lowering, as hypertension may represent a compensatory response to maintain cerebral perfusion pressure in the setting of posterior fossa mass effect 1, 2
• Avoid hypotension, which can worsen ischemia in at-risk tissue 1

Fluid and Metabolic Management

• Administer isotonic saline only; avoid hypotonic fluids and dextrose-containing solutions to prevent worsening cerebral edema 1
• Correct hypovolemia to ensure adequate cerebral perfusion pressure (CPP >60 mmHg) 1
• Maintain normoglycemia, avoiding hyperglycemia >180 mg/dL 2
• Treat fever >37.5°C aggressively, as hyperthermia worsens outcomes 2

Diagnostic Workup

• Complete the following investigations urgently: full blood count, electrolytes, renal function, fasting lipids, glucose, ECG, and inflammatory markers (ESR/CRP) 2
• Given normal MRA, consider additional vascular imaging with catheter angiography if vertebrobasilar dissection or vasculitis is suspected, particularly in a younger patient with dyslipidemia 2
• Prothrombotic screening may be indicated in this 41-year-old patient with bilateral infarcts and normal vessel imaging 2

Secondary Prevention Strategies

Lipid Management

• Initiate high-intensity statin therapy immediately for all patients with ischemic stroke, regardless of baseline lipid levels 2
• This should begin during hospitalization to improve adherence 2

Blood Pressure Control

• Antihypertensive medication should be started before discharge regardless of baseline BP for long-term secondary prevention 2
• Target BP control with lifestyle modifications including dietary changes and increased exercise 2

Lifestyle Modifications

• Smoking cessation counseling and interventions are essential 2
• Avoid excessive alcohol consumption 2

Common Pitfalls to Avoid

• Delaying neurosurgical consultation is the most critical error, as bilateral cerebellar infarcts can deteriorate suddenly and unpredictably, requiring emergency decompression 1, 3
• Failing to recognize that normal initial CT occurs in up to 25% of cerebellar infarcts; MRI is more sensitive 2
• Underestimating the risk of hydrocephalus from fourth ventricle compression, which requires urgent intervention 2, 3
• Aggressive blood pressure lowering in the acute phase, which may worsen perfusion to at-risk tissue 1
• Using corticosteroids for cerebral edema, which are not recommended and may increase infectious complications 2

Prognosis Considerations

• Partial territory cerebellar infarcts typically have benign outcomes with total recovery or minimal disability 4
• However, bilateral involvement increases risk for mass effect and requires vigilant monitoring during the critical first 72-96 hours 2
• Peak swelling occurs several days after onset, necessitating continued close observation even if initially stable 2