What is the management approach for an adult patient with a posterior stroke affecting the cerebellum and potential vascular risk factors?

Management of Posterior Cerebellar Stroke

Patients with cerebellar infarction require immediate admission to an intensive care or stroke unit with neurological monitoring capabilities, close surveillance for signs of brainstem compression or hydrocephalus, and early neurosurgical consultation, as approximately 25% will develop life-threatening mass effect and 85% of those progressing to coma will die without surgical intervention. 1

Immediate Triage and Monitoring

• Transfer to intensive care or stroke unit is mandatory for patients with large cerebellar infarcts to enable close monitoring and comprehensive treatment 1
• Neurosurgical consultation should be obtained immediately upon diagnosis, not after deterioration occurs, to facilitate rapid surgical planning if needed 1
• Transfer to a higher-level center should be initiated urgently if comprehensive neurosurgical care is not locally available 1
• Peak mass effect typically occurs on day 3 post-infarct but can develop throughout the first week, requiring vigilant monitoring during this entire period 1

Critical Warning Signs Requiring Urgent Intervention

Decreased level of consciousness is the single most reliable indicator of tissue swelling requiring immediate intervention 2. Additional warning signs include:

• Loss of corneal reflexes and development of miosis (indicating brainstem compression) 1
• New or worsening gait ataxia beyond initial presentation 3
• Fluctuating neurological examination suggesting intermittent brainstem compression 1
• Signs of hydrocephalus (occurs in up to 20% of cerebellar stroke patients) 1

Acute Medical Management

Airway and Basic Support

• Secure airway and provide adequate oxygenation to prevent hypoxemia and hypercarbia, which exacerbate cerebral edema 4
• Elevate head of bed to 20-30° to promote venous drainage 4
• Maintain blood glucose between 140-180 mg/dL per American Diabetic Association guidelines 1
• Avoid antihypertensive agents that cause cerebral vasodilation 4

Osmotic Therapy

• Administer mannitol 0.25-0.5 g/kg IV over 20 minutes as first-line osmotic therapy, with maximum effect within 10-15 minutes and duration of 2-4 hours 1, 4
• Mannitol can be repeated every 6 hours up to a maximum dose of 2 g/kg, though its effect is only temporizing before definitive surgical intervention 1
• Hypertonic saline may be considered as an alternative osmotic agent 4
• Restrict free water and avoid hypo-osmolar fluids that worsen cerebral edema 1, 4

Surgical Intervention

Indications for Surgery

Decompressive suboccipital craniectomy with durotomy and duraplasty is potentially life-saving and should be considered early, as half of patients progressing to coma who undergo surgical decompression achieve good outcomes 1. Key surgical considerations:

• Suboccipital decompressive craniectomy is superior to ventricular drain alone, as EVD placement carries risk of upward herniation and does not address brainstem mass effect 1
• Surgery should be performed before progression to coma rather than waiting for profound neurological dysfunction, as earlier intervention is associated with better outcomes 1
• For hydrocephalus with mass effect, combined ventricular drainage and decompressive surgery is recommended rather than EVD alone 1

Timing Considerations

• Do not delay surgery waiting for maximal deterioration—rapid surgical intervention in the setting of acute clinical deterioration improves outcome 1
• Conservative measures (head elevation, osmotic diuretics, hyperventilation) provide only transient benefit and should not delay definitive surgical treatment 1

Acute Revascularization (If Large Vessel Occlusion Present)

• Mechanical thrombectomy for basilar artery occlusion has demonstrated benefit in recent ATTENTION and BAOCHE trials, with newer devices (Solitaire stent retrievers, ACE catheters) achieving 92% recanalization rates 1, 5
• Successful recanalization is a strong predictor of favorable outcome (OR 4.57) and does not depend on thrombus length 1
• Thrombolysis appears to have similar benefits and lower hemorrhage risks in posterior circulation compared to anterior circulation 5
• Direct aspiration first pass technique (ADAPT) achieves higher complete reperfusion rates (OR 2.59) with shorter procedure duration and lower complication rates (4.3% vs 25.9%) compared to stent retrievers alone 1

Specific Clinical Profiles by Vascular Territory

Posterior Inferior Cerebellar Artery (PICA) Territory

• Presents with triad of vertigo, headache, and gait imbalance 3
• 30% develop severe cerebellar mass effect, with 19% progressing to fatal brainstem compression 3
• Requires more aggressive monitoring due to higher risk of complications 3

Superior Cerebellar Artery (SCA) Territory

• Presents predominantly with gait disturbance; vertigo and headache less common 3
• Clinical course usually more benign with only 7% developing marked mass effect 3
• Cerebral embolism is the predominant stroke mechanism 3

Secondary Prevention and Risk Factor Management

• Aggressive management of vascular risk factors is mandatory to prevent recurrent stroke and progressive cognitive impairment 2
• Short-term dual antiplatelet therapy should be initiated 5
• Atrial fibrillation screening and management is essential 2
• Blood pressure management should target maximum risk reduction while avoiding hypotension that compromises cerebral perfusion 2
• For basilar artery stenosis, medical therapy is superior to stenting due to high peri-procedural risk 5

Common Pitfalls to Avoid

• Do not rely on CT alone for early diagnosis—posterior fossa ischemia is rarely seen on early CT, and MRI is essential for accurate diagnosis 6
• Do not place EVD alone for hydrocephalus—this carries risk of upward herniation without addressing brainstem mass effect 1
• Do not wait for coma before considering surgery—85% of patients progressing to coma die without intervention, but half achieve good outcomes with early surgical decompression 1
• Do not underestimate the risk in PICA territory infarcts—these carry 30% risk of severe mass effect versus 7% for SCA infarcts 3
• Avoid insufficient neurological examination that omits coordination, gait, and eye movements, which can result in misdiagnosis 6