What is the acute management of a left cerebellar infarct?

Acute Management of Left Cerebellar Infarct

Immediately admit the patient to an intensive care or stroke unit with continuous neurological monitoring and obtain early neurosurgical consultation, as cerebellar infarcts can rapidly deteriorate into life-threatening emergencies requiring decompressive suboccipital craniectomy. 1, 2

Immediate Triage and Monitoring

• Transfer to ICU or stroke unit is mandatory for all patients with territorial cerebellar infarction, even if initially stable, as deterioration can occur up to 5 days after onset 1, 3
• Obtain neurosurgical consultation immediately upon admission to facilitate rapid surgical planning if the patient deteriorates—do not wait for clinical worsening 1, 2
• If your facility lacks neurosurgical capabilities or comprehensive stroke care, transfer urgently to a higher-level center 1

Critical Signs of Deterioration to Monitor

Watch closely for these warning signs that indicate need for urgent surgical intervention:

Clinical deterioration:

• Declining level of consciousness or Glasgow Coma Scale score <12 on admission, or decline of ≥2 points 2, 3
• New brainstem signs: pupillary anisocoria, pinpoint pupils, loss of oculocephalic responses, bradycardia, irregular breathing patterns, or sudden apnea 2, 3

Radiological deterioration:

• Fourth ventricular compression 2, 3
• Obstructive hydrocephalus 1, 2
• Brainstem displacement or compression of basal cisternae 1
• Hypodensity involving ≥2/3 of the cerebellar hemisphere 1

Airway Management

• Prepare for rapid sequence intubation if consciousness declines, GCS drops below 8-9, or the patient cannot protect their airway 1, 4
• Maintain normocapnia after intubation—prophylactic hyperventilation has no proven benefit 1
• Use short-acting sedatives (propofol or dexmedetomidine) if needed for ventilator synchrony while maintaining adequate mean arterial pressure 1

Medical Management

Positioning and basic measures:

• Elevate head of bed 0-30 degrees to help manage intracranial pressure 1, 2, 3
• Keep patient NPO (nothing by mouth) initially 1, 2

Fluid and metabolic management:

• Correct hypovolemia with isotonic fluids only—avoid hypotonic or dextrose-containing solutions 1, 2, 4
• Treat hyperglycemia to maintain glucose <8 mmol/L (144 mg/dL) 1, 2, 3
• Treat hyperthermia aggressively 1, 2, 3

Blood pressure management:

• Do not aggressively lower blood pressure in the acute phase—maintain systolic BP <220 mmHg and diastolic <120 mmHg to preserve cerebral perfusion 4
• Hypertension may be compensatory to maintain perfusion in the setting of brainstem compression 4

Antiplatelet therapy:

• Withhold antiplatelet agents if craniectomy is likely 1
• If craniectomy has been ruled out, administer aspirin 100-300 mg (or clopidogrel 75-300 mg if aspirin-intolerant) 1

Thromboembolism prophylaxis:

• Initiate subcutaneous low-dose heparin, low molecular weight heparin, or heparinoids for DVT prophylaxis 2, 3

Osmotic therapy:

• Mannitol or hypertonic saline is reasonable for patients with clinical deterioration from cerebral swelling 3

Surgical Management Algorithm

The decision for surgical intervention should follow this hierarchy:

For obstructive hydrocephalus with deterioration:

• Emergency ventriculostomy (external ventricular drain) is a reasonable first step if hydrocephalus is present 2, 5
• However, ventriculostomy must be accompanied by decompressive suboccipital craniectomy to prevent fatal upward cerebellar herniation 2, 3

For neurological deterioration from brainstem compression:

• Perform decompressive suboccipital craniectomy with dural expansion as the primary procedure 1, 2, 4, 3
• This should be done despite maximal medical therapy if deterioration occurs 2, 3

Timing considerations:

• Do not delay surgery once deterioration begins—outcomes worsen with delayed intervention beyond 24 hours from symptom onset 1
• Surgery leads to acceptable functional outcomes in most patients, and outcomes after cerebellar infarct can be good after suboccipital craniectomy 2, 3

Neuroimaging

• Non-contrast CT is the first-line test and should be used for serial monitoring in the first 2 days 1
• MRI with diffusion-weighted imaging is useful for early detection and volume measurement if available 1

Critical Pitfalls to Avoid

• Never perform ventriculostomy alone without planning for decompressive craniectomy—this can cause fatal upward herniation if significant edema develops 2, 4, 3
• Do not delay neurosurgical consultation until deterioration occurs—early involvement is essential for optimal outcomes 1, 2, 4
• Do not use hypothermia, barbiturates, or corticosteroids for ischemic cerebellar swelling—these lack sufficient evidence and are not recommended 2, 3
• Do not assume stability means safety—patients can deteriorate up to 5 days after onset even if initially stable 1, 3

Prognostic Counseling

• Inform family members that outcomes can be good after suboccipital craniectomy for cerebellar infarction 2, 3
• Engage in shared decision-making quickly with patients (if possible) and caregivers, including patient-centered preferences when considering interventions 2
• The only known predictor of unfavorable outcome is advanced brainstem dysfunction such as locked-in syndrome 1