Surgical treatment of malignant cerebellar infarction

The study objective is to evaluate the effectiveness of various methods of surgical treatment of malignant cerebellar infarction.

Materials and methods. There were 47 patients with malignant cerebellar infarction retrospectively analyzed in this study. The group 1 included all patients who underwent surgical treatment (n = 31), the group 2 included all patients who underwent conservative treatment (n = 16). In the group 1, 15 patients underwent isolated ventriculostomy, 4 – posterior fossa decompression (PFD), 14 – combination of ventriculostomy and PFD. The criteria of efficacy of surgery were: restoration of consciousness, restoration of forth ventricle and the quadrigeminal cistern configurations. Results of treatment were assessed according to the Glasgow outcome scale.

Results. The recovery of consciousness level was observed in 7 out of 15 patients after isolated ventriculostomy on average 13 day; the efficacy was 47 %. Four patients underwent only PFD. Among them 2 patients needed additional external ventricular drainage installation as 2nd operation. The efficacy was 50 %. After PFD with simultaneous ventriculostomy the recovery of consciousness was observed on 4 day in 11 out of patients. The efficacy was 79 %. Combined ventriculostomy and PFD were 32 % more effective than ventriculostomy alone, and 29 % more effective than PFD alone.

Conclusion. In patients with malignant cerebellar infarction with a decrease in consciousness and signs of brainstem compression, ventriculostomy with PFD are advisable, because isolated ventriculostomy does not always provide a necessary effect in decompensation of dislocation syndrome.

1. Krylov V.V., Nikitin A.S., Dashyan V.G. et al. Surgery of a massive ischemic stroke. M.: Geotar-Media, 2016. 136 p. (In Russ.).

2. Levada O.A. Etiology, clinical variants, diagnosis and treatment tactic of cerebellar infarction. Лiкарська справа = Lik Sprava 2003;(5–6):3–6. PMID: 14618791.

3. Mohr J. Stroke: Pathophysiology, diagnosis, and management. 5th edn. Philadelphia: Elsevier, 2011. Pp. 750–752.

4. Macdonell R.A., Kalnins R.M., Donnan G.A. Cerebellar infarction: natural history, prognosis, and pathology. Stroke 1987;18(5):849–55. PMID: 3629642.

5. Greenberg J., Skubick D., Shenkin H. Neurology 1979;29(3): 409–13. PMID: 571991.

6. Klugkist H., McCarthy J. Surgical treatment of space-occupying cerebellar infarctions – 4 1/2 years post-operative follow-up. Neurosurg Rev 1991;14(1): 17–22. PMID: 2030823.

7. Neugebauer H., Witsch J., Zweckberger K., Jüttler E. Space occupying cerebellar infarction: complications, treatment, and outcome. Neurosurg Focus 2013;34(5):E8. DOI: 10.3171/2013.2.FOCUS12363. PMID: 23634927.

8. Tohgi H., Takahashi S., Chiba K., Hirata Y. Cerebellar infarction. Clinical and neuroimaging analysis in 293 patients. The Tohoku Cerebellar Infarction Study Group. Stroke 1993;24(11):1697–701. PMID: 8236346.

9. Hornig C.R., Rust D.S., Busse O. et al. Space-occupying cerebellar infarction. Clinical course and prognosis. Stroke 1994;25(2):372–4. PMID: 8303748.

10. Koh M.G., Phan T.G., Atkinson J.L., Wijdicks E.F. Neuroimaging in deteriorating patients with cerebellar infarcts and mass effect. Stroke 2000;31(9):2062–7. PMID: 10978030.

11. Bussaka H., Sakamoto Y., Hatanaka Y. et al. [Cerebellar infarction; the findings of CT, MRI and cerebral angiography (In Japanese)]. Rinsho Hoshasen 1990;35(4):445–51. PMID: 2355644.

12. Chen W., Fang J., Dong Y.R. et al. Teaching neuroimages: isolated vertigo and imbalance due to deep border zone cerebellar infarct. Neurology 2011;77(21):e122. DOI: 10.1212/WNL.0b013e318238ee31. PMID: 22105956.

13. Jauss M., Krieger D., Hornig C. et al. Surgical and medical management of patients with massive cerebellar infarctions: results of the German-Austrian Cerebellar Infarction Study. J Neurol 1999;246(4):257–64. PMID: 10367693.

14. Raco A., Caroli E., Isidori A., Salvati M. Management of acute cerebellar infarction: one institution’s experience. Neurosurgery 2003;53(5):1061–5. PMID: 14580272.

15. Tsitsopoulos P.P., Tobieson L., Enblad P., Marklund N. Surgical treatment of patients with unilateral cerebellar infarcts: clinical outcome and prognostic factors. Acta Neurochir (Wien) 2011;153(10):2075–83. DOI: 10.1007/s00701-011-1120-4. PMID: 21833781.

16. Simard J.M., Chen M., Tarasov K.V. et al. Newly expressed SUR1-regulated NC(Ca-ATP) channel mediates cerebral edema after ischemic stroke. Nat Med 2006;12(4):433–40. DOI: 10.1038/nm1390. PMID: 16550187.

17. Tsitsopoulos P.P., Tobieson L., Enblad P., Marklund N. Clinical outcome following surgical treatment for bilateral cerebellar infarction. Acta Neurol Scand 2011;123(5):345–51. DOI: 10.1111/j.16000404.2010.01404.x. PMID: 20636449.

18. Wijdick E.F., Sheth K.N., Carter B.S. et al. Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke 2014;45(4):1222–38. DOI: 10.1161/01.str.0000441965.15164. d6. PMID: 24481970.

19. Asratian S.A., Nikitin A.S. Dislocation syndrome induced by massive cerebellar infarction and indications for urgent operation. Zhurnal nevrologii i psikhiatri im. S.S. Korsakova. Spetsvypuski = S.S. Korsakov Journal of Neurology and Psychiatry. Special issues 2012;112(12):55–60. (In Russ.).

20. Godkov I.M., Luk’yanchikov V.A. The surgical treatment of patients with cerebellar ischemic stroke. Neyrokhirurgiya = Russian Journal of Neurosurgery 2015;(3):84–90. (In Russ.).

21. Jauss M., Müffelmann B., Krieger D. et al. A computed tomography score for assessment of mass-effect in spaceoccupying cerebellar infarction. J Neuroimaging 2001;11(3):268–71. PMID: 11462293.

22. Keidel M., Galle G., Wiedmayer J., Taghavy A. [Malignant cerebellar infarct (In German)]. Fortschr Neurol Psychiatr 1984;52(8):277–83. DOI: 10.1055/s-2007-1002025. PMID: 6479828.

23. Mathew P., Teasdale G., Bannan A., Oluoch-Olunya D. Neurosurgical management of cerebellar haematoma and infarct. J Neurol Neurosurg Psychiatry 1995;59(3):287–92. PMID: 7673958.

24. Baldauf J., Oertel J., Gaab M.R., Schroeder H.W. Endoscopic third ventriculostomy for occlusive hydrocephalus caused by cerebellar infarction. Neurosurgery 2006;59(3):539–44. DOI: 10.1227/01.NEU.0000228681.45125.E9. PMID: 16955035.

25. Khan I., Burhan Janjua M., Khatri I., Nadeem M. Surgical decompression in massive cerebellar stroke. Rawal Med J 2010;35(1):96–100.

26. Orz Y., Naggar A., Issa A. et al. Posterior fossa decompression in acute cerebellar infarction. Pan Arab J Neurosurg 2008;12(1):50–4.

27. Fairburn B., Oliver L.C. Cerebellar softening; a surgical emergency. Br Med J 1956;1(4979):1335–6. PMID: 13316146.

28. Jüttler E., Schweickert S., Ringleb P.A. et al. Long-term outcome after surgical treatment for space-occupying cerebellar infarction: experience in 56 patients. Stroke 2009;40(9):3060–6. DOI: 10.1161/STROKEAHA.109.550913. PMID: 19574554.

29. Kudo H., Kawaguchi T., Minami H. et al. Controversy of surgical treatment for severe cerebellar infarction. J Stroke Cerebrovasc Dis 2007;16(6):259–62. DOI: 10.1016/j.jstrokecerebrovasdis.2007.09.001. PMID: 18035243.

30. Pfefferkorn T., Epinger U., Linn J. et al. Long-term outcome after suboccipital decompressive craniectomy for malignant cerebellar infarction. Stroke 2009;40(9):3045–50. DOI: 10.1161/STROKEAHA.109.550871. PMID: 19574555.