Management of Cerebellar Subacute Infarct

Initial Triage and Monitoring

For a patient with cerebellar subacute infarct, immediate admission to an intensive care or stroke unit with close neurological monitoring is essential, with early neurosurgical consultation to facilitate timely decompressive suboccipital craniectomy if neurological deterioration occurs from brainstem compression or obstructive hydrocephalus 1, 2
Admit all patients with cerebellar infarction to an intensive care or stroke unit for comprehensive treatment and close monitoring, even if initially stable 3
Obtain early neurosurgical consultation to facilitate planning of potential decompressive surgery or ventriculostomy if the patient deteriorates 4, 3
If comprehensive care and timely neurosurgical intervention are not available locally, transfer to a higher level center is reasonable 4

Watch closely for clinical deterioration manifesting as depression in consciousness level or Glasgow Coma Scale score <12 on admission, or decline of ≥2 points 3
New brainstem signs: pupillary anisocoria, pinpoint pupils, loss of oculocephalic responses, bradycardia, irregular breathing patterns, sudden apnea 3
Radiographic deterioration: fourth ventricular compression and evidence of hydrocephalus 3

Elevate the upper body between 0° and 30° to help manage intracranial pressure 3
Ensure sufficient cerebral oxygenation and correct hypovolemia with isotonic fluids 3
Avoid oral intake of food and fluids initially 3
Treat hyperthermia and maintain normoglycemia (glucose <8 mmol/L) 3
Initiate thromboembolic prophylaxis with subcutaneous low-dose heparin, low molecular weight heparin, or heparinoids 3

If the patient develops symptoms of obstructive hydrocephalus, emergency ventriculostomy is a reasonable first step in the surgical management paradigm 1, 2
If cerebrospinal diversion by ventriculostomy fails to improve neurological function, decompressive suboccipital craniectomy should be performed 1
When ventriculostomy is needed, it should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement 3
Decompressive suboccipital craniectomy with dural expansion should be performed in patients with cerebellar infarction causing neurological deterioration from brainstem compression despite maximal medical therapy 1, 2
When deemed safe and indicated, obstructive hydrocephalus should be treated concurrently with ventriculostomy 1, 2

When considering decompressive suboccipital craniectomy for cerebellar infarction, it may be reasonable to inform family members that the outcome after cerebellar infarct can be good after suboccipital craniectomy 1, 2
Surgery after cerebellar infarct leads to acceptable functional outcomes in most patients 3

Do not use hypothermia, barbiturates, or corticosteroids for ischemic cerebellar swelling, as they lack sufficient evidence 3
Do not perform ventriculostomy alone without planning for potential decompressive craniectomy, as this can lead to upward herniation if significant edema or mass effect develops 1
Do not delay neurosurgical consultation until deterioration occurs; early involvement is essential for optimal outcomes 4, 3

Discussion of care options and possible outcomes should take place quickly with patients (if possible) and caregivers 1
Medical professionals should ascertain and include patient-centered preferences in shared decision making, especially during prognosis formation and when considering interventions or limitations in care 1