Initial Management of Cerebellar Stroke

Recognition and Monitoring

Patients with cerebellar infarction should be closely monitored for level of arousal or new brainstem signs, which indicate deterioration 3
Clinical deterioration in cerebellar infarcts manifests as brainstem compression, depression in consciousness level, Glasgow Coma Scale score <12 on admission, or a decline of ≥2 points 3
Radiographic deterioration appears as fourth ventricular compression and evidence of hydrocephalus 3
Patients with territorial cerebellar infarctions require monitoring for up to 5 days, even if initially stable 4

Transfer to an intensive care or stroke unit is essential for comprehensive treatment and close monitoring 5
Elevate the upper part of the body between 0° and 30° to help manage intracranial pressure 4
Ensure sufficient cerebral oxygenation and correct hypovolemia with isotonic fluids 4
Avoid oral intake of food and fluids initially 4
Treat hyperthermia and maintain normoglycemia (glucose <8 mmol/L) 4
Osmotic therapy (mannitol or hypertonic saline) is reasonable for patients with clinical deterioration from cerebral swelling 3
Thromboembolic prophylaxis with subcutaneous low-dose heparin, low molecular weight heparin, or heparinoids should be initiated 4

Neurosurgical consultation should be sought early to facilitate planning of potential decompressive surgery 5
In patients with cerebellar stroke who deteriorate neurologically, suboccipital craniectomy with dural expansion should be performed 1
If ventriculostomy is needed to relieve obstructive hydrocephalus, it should be accompanied by decompressive suboccipital craniectomy to avoid upward cerebellar displacement 1
Surgery after cerebellar infarct leads to acceptable functional outcomes in most patients 1

Hypothermia, barbiturates, and corticosteroids lack sufficient evidence in the setting of ischemic cerebellar swelling and are not recommended 3

Monitor for signs of brainstem compression: pupillary anisocoria, pinpoint pupils, loss of oculocephalic responses, bradycardia, irregular breathing patterns, and sudden apnea 3
Watch for development of obstructive hydrocephalus, which is a secondary manifestation in most instances of cerebellar swelling 3

Clinicians may discuss with family members that the outcome after cerebellar infarct can be good after suboccipital craniectomy 6