Surgical Management of Cerebellar Infarct
Cerebellar infarct requires surgical intervention when neurological deterioration occurs from brainstem compression or obstructive hydrocephalus despite maximal medical therapy. Not all cerebellar infarcts are surgical—the decision depends on clinical deterioration, mass effect, and hydrocephalus development.
Initial Triage and Monitoring
All patients with cerebellar infarction should be admitted to an intensive care or stroke unit with early neurosurgical consultation, even if initially stable 1, 2. This allows for:
- Close neurological monitoring with serial examinations 2
- Early planning for potential surgical intervention if deterioration occurs 1
- Transfer to a higher-level center if comprehensive neurosurgical care is unavailable locally 1, 2
Critical Signs Requiring Surgical Consideration
Watch for these indicators of deterioration 2:
- Declining level of consciousness (Glasgow Coma Scale <12 or decline ≥2 points)
- Brainstem compression signs: pupillary abnormalities, loss of oculocephalic responses, bradycardia, irregular breathing, sudden apnea
- Radiographic findings: fourth ventricular compression, obstructive hydrocephalus, significant mass effect
Surgical Management Algorithm
Step 1: Ventriculostomy for Hydrocephalus
If obstructive hydrocephalus develops, emergency ventriculostomy is the reasonable first surgical step 1, 2. Ventriculostomy alone can be effective in relieving symptoms in many patients 1.
Step 2: Decompressive Craniectomy
Decompressive suboccipital craniectomy with dural expansion should be performed when:
- Neurological deterioration continues despite maximal medical therapy and brainstem compression is evident 1, 2
- Ventriculostomy fails to improve neurological function 1, 2
- Significant cerebellar edema or mass effect develops 1
Critical pitfall to avoid: Ventriculostomy alone in the setting of significant cerebellar mass effect can cause upward herniation 1. When ventriculostomy is needed, it should be accompanied by decompressive suboccipital craniectomy to prevent deterioration from upward cerebellar displacement 1, 2.
Medical Management (Non-Surgical Cases)
Approximately 57% of cerebellar infarct patients can be managed conservatively without surgery 3. Medical management includes:
- Elevate head of bed 0-30 degrees 2
- Isotonic fluid resuscitation to correct hypovolemia 2
- Maintain normothermia and normoglycemia (glucose <8 mmol/L) 2
- Thromboembolic prophylaxis with subcutaneous heparin 2
- Avoid hypotonic fluids and oral intake initially 2
Do not use hypothermia, barbiturates, or corticosteroids for ischemic cerebellar swelling—they lack sufficient evidence 2.
Prognosis and Counseling
Surgery after cerebellar infarct leads to acceptable functional outcomes in most patients 1, 2. When considering decompressive surgery, families should be informed that outcomes can be good after suboccipital craniectomy 1, 2.
In surgical series, 59-70% of operated patients achieved good functional recovery or minimal assistance requirements 3, 4, 5. Even among comatose patients undergoing surgery, meaningful recovery is possible in approximately half 6.
Key Decision Points
The level of consciousness is the most powerful predictor of outcome, superior to any other clinical sign 6. Deterioration typically occurs between days 2-4, with maximum risk on day 3 6.
Shared decision-making with patients and families should occur quickly, incorporating patient-centered preferences regarding interventions and limitations of care 1, 2.