What is the anatomy and physiology of a cerebellar (cerebral) stroke, also known as a cerebellar infarction (lack of blood flow) or cerebellar hemorrhage (bleeding)?

From the Guidelines

A cerebellar stroke is a life-threatening condition that requires prompt recognition and treatment to prevent severe morbidity and mortality, and the most effective treatment approach is often a combination of medical management and surgical intervention, as recommended by the 2018 guidelines for the early management of patients with acute ischemic stroke 1. The cerebellum is a critical brain structure located at the back of the brain, beneath the occipital lobes and posterior to the brainstem, and it receives blood supply primarily from three arteries: the superior cerebellar artery, the anterior inferior cerebellar artery, and the posterior inferior cerebellar artery. Anatomically, the cerebellum consists of two hemispheres connected by the vermis and contains three functional zones: the vestibulocerebellum, spinocerebellum, and cerebrocerebellum. Physiologically, the cerebellum coordinates voluntary movements, maintains posture and balance, and participates in motor learning.

When a stroke occurs, patients typically present with vertigo, ataxia, dysarthria, nystagmus, and ipsilateral limb incoordination. Treatment focuses on stabilizing the patient, managing blood pressure, and preventing complications. Surgical intervention, such as decompressive suboccipital craniectomy with dural expansion, may be necessary for large cerebellar strokes causing brainstem compression or hydrocephalus, as recommended by the 2018 guidelines 1. Early recognition is crucial as cerebellar strokes can rapidly deteriorate due to edema in the confined posterior fossa, potentially leading to brainstem compression and life-threatening complications.

The management of cerebral and cerebellar infarction with swelling requires a multidisciplinary approach, including admission to intensive care or stroke units, complex medical care, and surgical intervention, as recommended by the 2014 guidelines for the management of cerebral and cerebellar infarction with swelling 1. The outcome of cerebellar stroke can be satisfactory, but one should anticipate that some patients will be severely disabled and fully dependent on care even after decompressive craniectomy. Surgical intervention, such as decompressive suboccipital craniectomy with dural expansion, should be performed in patients who deteriorate neurologically, and ventriculostomy to relieve obstructive hydrocephalus after a cerebellar infarct should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement, as recommended by the 2018 guidelines 1.

Some key points to consider in the management of cerebellar stroke include:

• Early recognition and treatment are crucial to prevent severe morbidity and mortality
• Surgical intervention, such as decompressive suboccipital craniectomy with dural expansion, may be necessary for large cerebellar strokes causing brainstem compression or hydrocephalus
• Ventriculostomy to relieve obstructive hydrocephalus after a cerebellar infarct should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement
• The outcome of cerebellar stroke can be satisfactory, but one should anticipate that some patients will be severely disabled and fully dependent on care even after decompressive craniectomy.

From the Research

Anatomy of Cerebellar Stroke

• The cerebellum is supplied by three pairs of arteries: AICA (anterior inferior cerebellar artery), PICA (posterior inferior cerebellar artery), and SCA (superior cerebellar artery) 2
• These arteries have many anastomoses between them, making the cerebellum less susceptible to stroke, especially ischemic stroke 2
• The cerebellum is located in the posterior fossa, and stroke in this region can be difficult to diagnose due to the lower sensitivity of commonly used CT scans 3, 2

Physiology of Cerebellar Stroke

• Cerebellar stroke can present with non-specific symptoms such as dizziness, nausea and vomiting, unsteady gait, and headache 3
• The clinical presentation of cerebellar stroke can be different from common stroke syndromes in the anterior cerebral circulation 4
• Cerebellar stroke can initially mimic benign vestibular neuritis and may later deteriorate into a life-threatening neurologic state 4
• Posterior circulation stroke presents similarly in children and adults, but the possibly mild symptoms and signs at onset are frequently overlooked by parents and healthcare professionals 4

Diagnosis and Treatment of Cerebellar Stroke

• Accurate diagnosis of cerebellar stroke frequently relies on careful attention to patients' coordination, gait, and eye movements 3
• Early correct diagnosis is crucial to help prevent treatable but potentially fatal complications, such as brainstem compression and obstructive hydrocephalus 3
• The identification and treatment of the underlying vascular lesions at an early stage can also prevent subsequent occurrences of stroke and improve patients' outcomes 3
• Antithrombotic agents, such as antiplatelet agents and anticoagulants, can be used to prevent stroke, but the choice of agent depends on the pathogenesis of the stroke 5