What is the management of a malignant cerebellar infarct?

Management of Malignant Cerebellar Infarct

Patients with malignant cerebellar infarction require immediate admission to an intensive care or stroke unit with early neurosurgical consultation, and should undergo suboccipital decompressive craniectomy with dural expansion if neurological deterioration occurs from brainstem compression or obstructive hydrocephalus. 1, 2

Immediate Recognition and Triage

All patients with cerebellar infarction, even if initially stable, must be admitted to an intensive care or stroke unit for close monitoring for up to 5 days. 1, 2 The term "malignant" refers to large territorial infarcts that swell within 24 hours causing brain herniation signs, and rapid deterioration from cerebellar infarcts with swelling may be associated with sudden apnea from brainstem compression and cardiac arrhythmias. 3

Critical Signs of Deterioration to Monitor

Watch for these specific clinical indicators that signal impending catastrophe:

• Depression in consciousness level or Glasgow Coma Scale score <12 on admission, or decline of ≥2 points 1, 2
• Brainstem compression signs: pupillary anisocoria, pinpoint pupils, loss of oculocephalic responses, bradycardia, irregular breathing patterns, and sudden apnea 1, 2
• Radiographic deterioration: fourth ventricular compression and evidence of hydrocephalus on imaging 1, 2

Deterioration typically occurs between days 2 and 4, with a maximum on day 3. 4

Early Neurosurgical Consultation

Obtain neurosurgical consultation immediately upon diagnosis, not after deterioration begins. 1, 2 This early involvement is essential for optimal outcomes and allows for rapid surgical intervention when needed. If comprehensive care and timely neurosurgical intervention are not available locally, transfer to a higher level center is reasonable. 2

Medical Management

Supportive Care Measures

• Elevate the head of bed between 0° and 30° to help manage intracranial pressure 1, 2
• Ensure sufficient cerebral oxygenation and correct hypovolemia with isotonic fluids 1, 2
• Avoid oral intake of food and fluids initially 1, 2
• Treat hyperthermia aggressively and maintain normoglycemia (glucose <8 mmol/L) 1, 2
• Initiate thromboembolic prophylaxis with subcutaneous low-dose heparin, low molecular weight heparin, or heparinoids 1, 2

Osmotic Therapy

Osmotic therapy with mannitol or hypertonic saline is reasonable for patients with clinical deterioration from cerebral swelling. 1 For mannitol, the recommended dosage is 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over 30 to 60 minutes. 5 Mannitol reduces intracranial pressure by increasing osmotic pressure of plasma and extracellular space, inducing movement of intracellular water to the extracellular and vascular spaces. 5

Therapies to Avoid

Do not use hypothermia, barbiturates, or corticosteroids for ischemic cerebellar swelling, as they lack sufficient evidence. 1, 2

Surgical Management Algorithm

The surgical approach depends on the clinical presentation and response to initial interventions:

For Obstructive Hydrocephalus

If the patient develops symptoms of obstructive hydrocephalus, emergency ventriculostomy is a reasonable first step. 2 However, ventriculostomy must be accompanied by decompressive suboccipital craniectomy to avoid upward cerebellar displacement and herniation. 1, 2 This is a critical pitfall to avoid—ventriculostomy alone can precipitate upward herniation if significant edema or mass effect is present. 2

For Neurological Deterioration

In patients with cerebellar stroke who deteriorate neurologically despite maximal medical therapy, perform suboccipital craniectomy with dural expansion. 1, 2 This procedure should include removal of necrotic tissue when appropriate. 3, 6

Research supports this approach: in a study of 57 patients treated with bilateral suboccipital decompressive craniectomy, there were no fatal procedural complications, and 40% of survivors lived functionally independent (mRS 0-2) at long-term follow-up. 7 Another study found that half of all patients deteriorating to coma who were treated with ventricular drainage or decompressive craniotomy had meaningful recovery. 4

Timing of Surgery

Do not delay surgical intervention once deterioration begins. 1, 2 The level of consciousness is the most powerful predictor of outcome, superior to any other clinical sign. 4 Patients who are awake/drowsy or somnolent/stupor at the time of intervention have better outcomes than those who progress to coma. 4

Prognostic Factors and Counseling

Inform family members that outcome after cerebellar infarct can be good after suboccipital craniectomy, with surgery leading to acceptable functional outcomes in most patients. 1, 2 However, be aware that:

• The presence of additional brainstem infarction is associated with poor outcome (hazard ratio: 9.1) 7
• Advanced age and brainstem involvement are predictors for poor long-term outcome 8
• Overall mortality within the first 6 months after surgery is approximately 28% 7

Common Pitfalls to Avoid

• Do not perform ventriculostomy alone without planning for decompressive craniectomy—this can lead to upward herniation 2
• Do not delay neurosurgical consultation until deterioration occurs—early involvement is essential 1, 2
• Do not use intravenous heparin due to risk of hemorrhagic transformation, but subcutaneous heparin or low molecular weight heparin is necessary for DVT prophylaxis 9
• Do not underestimate the risk of sudden deterioration even in initially stable patients—territorial cerebellar infarctions require monitoring for up to 5 days 1

Monitoring for Complications

Discontinue mannitol if renal, cardiac, or pulmonary status worsens, or CNS toxicity develops. 3 Monitor cardiovascular status and electrolyte levels, as mannitol may cause fluid and electrolyte imbalances, hypernatremia, hyponatremia, and may intensify congestive heart failure. 5