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Dubinski D, Won SY, Mattes I, Trnovec S, Behmanesh B, Cantré D, Baumgarten P, Dinc N, Konczalla J, Wittstock M, Freiman TM, Gessler F. Frailty in cerebellar ischemic stroke-The significance of temporal muscle thickness. Front Neurol 2023; 14:1193685. [PMID: 37822528 PMCID: PMC10562580 DOI: 10.3389/fneur.2023.1193685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 09/04/2023] [Indexed: 10/13/2023] Open
Abstract
While comprising only 2% of all ischemic strokes, cerebellar strokes are responsible for substantial morbidity and mortality due to their subtle initial presentation and the morbidity of posterior fossa swelling. Furthermore, low temporal muscle thickness (TMT) has recently been identified as a prognostic imaging parameter to assess patient frailty and outcome. We analyzed radiological and clinical data sets of 282 patients with cerebellar ischemic stroke. Our analysis showed a significant association between low TMT, reduced NIHSS and mRS at discharge (p = 0.035, p = 0.004), and reduced mRS at 12 months (p = 0.001). TMT may be used as a prognostic imaging marker and objective tool to assess outcomes in patients with cerebellar ischemic stroke.
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Affiliation(s)
- Daniel Dubinski
- Department of Neurosurgery, University Medicine Rostock, Rostock, Germany
| | - Sae-Yeon Won
- Department of Neurosurgery, University Medicine Rostock, Rostock, Germany
| | - Isabell Mattes
- Department of Neurosurgery, University Medicine Rostock, Rostock, Germany
| | - Svorad Trnovec
- Department of Neurosurgery, University Medicine Rostock, Rostock, Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Medicine Rostock, Rostock, Germany
| | - Daniel Cantré
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medicine Rostock, Rostock, Germany
| | - Peter Baumgarten
- Department of Neurosurgery, University Hospital, Schiller University Jena, Jena, Germany
| | - Nazife Dinc
- Department of Neurosurgery, University Hospital, Schiller University Jena, Jena, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | | | - Thomas M. Freiman
- Department of Neurosurgery, University Medicine Rostock, Rostock, Germany
| | - Florian Gessler
- Department of Neurosurgery, University Medicine Rostock, Rostock, Germany
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David AM, Jaleel A, Joy Mathew CM. Misdiagnosis of Cerebellar Infarcts and Its Outcome. Cureus 2023; 15:e35362. [PMID: 36974239 PMCID: PMC10039737 DOI: 10.7759/cureus.35362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2023] [Indexed: 02/25/2023] Open
Abstract
Cerebellar infarction, a rare category of stroke, is often misdiagnosed but not given much importance in the available literature. Its presentation overlaps with symptoms of other neurologic, cardiovascular, gastrointestinal, and systemic conditions and therefore is nonspecific. Early diagnosis and management of cerebellar strokes are of utmost importance as the lack of a proper diagnosis may increase overall morbidity and mortality. Lack of awareness of the warning signs and symptoms, non-specificity of symptoms, absence of neurological deficits, and imaging discrepancies are some of the factors contributing to misdiagnosis and delayed treatment. If symptomatology is considered, it is found that symptoms of posterior circulation stroke were more frequently misdiagnosed compared to anterior circulation. Nausea and vomiting increased the chance further. Some other rare presentations include gastrointestinal symptoms, isolated vertigo, and symptoms of inner ear disease. Overdependence on radiological investigations often masks the significance of clinical examination. Ischemic stroke may appear normal in the initial 48 hours in the computed tomography scan of the brain or bony artefacts may hide the lesion. Permanent disabling deficits can follow a cerebellar stroke and the complications, which include hydrocephalus, brain stem compression, and gait abnormalities, necessitate prompt identification and management. In this review article, we aim at analysing various case reports of cerebellar infarction, the most common presentations that were under-evaluated, and their outcomes, thereby highlighting the importance of proper diagnosis and reporting of cerebellar infarction in the future. A thorough knowledge of the association between various clinical presentations of cerebellar stroke and its misdiagnosis helps clinicians to be more vigilant about the disease.
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Rate of Infarct-Edema Growth on CT Predicts Need for Surgical Intervention and Clinical Outcome in Patients with Cerebellar Infarction. Neurocrit Care 2021; 36:1011-1021. [PMID: 34966956 PMCID: PMC9110544 DOI: 10.1007/s12028-021-01414-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/29/2021] [Indexed: 10/31/2022]
Abstract
BACKGROUND Up to 20% of patients with cerebellar infarcts will develop malignant edema and deteriorate clinically. Radiologic measures, such as initial infarct size, aid in identifying individuals at risk. Studies of anterior circulation stroke suggest that mapping early edema formation improves the ability to predict deterioration; however, the kinetics of edema in the posterior fossa have not been well characterized. We hypothesized that faster edema growth within the first hours after acute cerebellar stroke would be an indicator for individuals requiring surgical intervention and those with worse neurological outcomes. METHODS Consecutive patients admitted to the neurological intensive care unit with acute cerebellar infarction were retrospectively identified. Hypodense regions of infarct and associated edema, "infarct-edema", were delineated by using ABC/2 for all computed tomography (CT) scans up to 14 days from last known well. To examine how rate of infarct-edema growth varied across clinical variables and surgical intervention status, nonlinear and linear mixed-effect models were performed over 2 weeks and 2 days, respectively. In patients with at least two CT scans, multivariable logistic regression examined clinical and radiological predictors of surgical intervention (defined as extraventricular drainage and/or posterior fossa decompression) and poor clinical outcome (discharge to skilled nursing facility, long-term acute care facility, hospice, or morgue). RESULTS Of 150 patients with acute cerebellar infarction, 38 (25%) received surgical intervention and 45 (30%) had poor clinical outcome. Age, admission National Institutes of Health Stroke Scale (NIHSS) score, and baseline infarct-edema volume did not differ, but bilateral/multiple vascular territory involvement was more frequent (87% vs. 50%, p < 0.001) in the surgical group than that in the medical intervention group. On 410 serial CTs, infarct-edema volume progressed rapidly over the first 2 days, followed by a subsequent plateau. Of 112 patients who presented within two days, infarct-edema growth rate was greater in the surgical group (20.1 ml/day vs. 8.01 ml/day, p = 0.002). Of 67 patients with at least two scans, after adjusting for baseline infarct-edema volume, vascular territory, and NIHSS, infarct-edema growth rate over the first 2 days (odds ratio 2.55; 95% confidence interval 1.40-4.65) was an independent, and the strongest, predictor of surgical intervention. Further, early infarct-edema growth rate predicted poor clinical outcome (odds ratio 2.20; 95% confidence interval 1.30-3.71), independent of baseline infarct-edema volume, brainstem infarct, and NIHSS. CONCLUSIONS Early infarct-edema growth rate, measured via ABC/2, is a promising biomarker for identifying the need for surgical intervention in patients with acute cerebellar infarction. Additionally, it may be used to facilitate discussions regarding patient prognosis.
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Abdelbari Mattar M, Maher H, K. Zakaria W. The impact of emergent suboccipital craniectomy upon outcome & prognosis of massive cerebellar infarction: A single institutional study. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Borojevic B, Choi PMC. Early space-occupying cerebellar oedema requiring decompressive craniectomy following a clinically minor stroke. BMJ Case Rep 2021; 14:14/7/e243815. [PMID: 34312138 PMCID: PMC8314700 DOI: 10.1136/bcr-2021-243815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We describe a patient presented with clinically a small cerebellar ischaemic stroke but required emergency decompression within 24 hours of symptoms onset after incidental finding of severe mass effect on imaging without any change in her mild clinical symptoms. Her initial multimodal acute stroke imaging, non-contrast CT of the brain and CT angiography from aortic arch to vertex were normal. CT perfusion showed a very small deficit only. The malignant mass effect was picked on an MRI scan performed routinely as part of a clinical trial, 32 hours after stroke. Our case highlights stroke evolution, and mass effect may be insidious and faster than anticipated in the posterior fossa. Cerebellar stroke of any severity diagnosed clinically and radiologically may benefit from routine follow-up imaging at 24 hours from onset.
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Affiliation(s)
- Branko Borojevic
- Department of Neurosciences, Eastern Health, Box Hill, Victoria, Australia
| | - Philip M C Choi
- Department of Neurosciences, Eastern Health, Box Hill, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
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Sarikaya H, Steinlin M. Cerebellar stroke in adults and children. HANDBOOK OF CLINICAL NEUROLOGY 2018; 155:301-312. [DOI: 10.1016/b978-0-444-64189-2.00020-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Guo YL, Zhang ZP, Zhang GS, Kong LM, Rao HB, Chen W, Wang GW, Shen ZW, Zheng WB, Wu RH. Evaluation of mean diffusion and kurtosis MRI mismatch in subacute ischemic stroke: Comparison with NIHSS score. Brain Res 2016; 1644:231-9. [PMID: 27208488 DOI: 10.1016/j.brainres.2016.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 05/06/2016] [Accepted: 05/11/2016] [Indexed: 02/05/2023]
Abstract
Neurological deterioration (ND) is a devastating complication following ischemic stroke. This study aimed to identify the differences in lesion characteristics in subacute ischemic stroke patients with and without ND using diffusional kurtosis imaging (DKI), as well as to confirm the responsible lesions that may lead to ND, as assessed by the National Institutes of Health Stroke Scale (NIHSS) score. Seventy-nine patients with subacute cerebral infarction were allocated to the ND (-) and ND (+) groups according to the NIHSS score and lesion number. The mean diffusion (MD) lesions were significantly larger than the mean kurtosis (MK) deficits in the ND (+) group (P<0.05); however, there was no significant difference in the ND (-) group (P>0.05). The MD and MK in the lesion recovered to normal levels over time; however, the recovery trends in the ND (+) group were substantially slower than the ND (-) group. The differences between the two groups were only significant regarding the MK (p<0.05). Furthermore, multiple infarction lesions exhibited good consistency in the ND (-) group, but were non-homogeneous in the ND (+) group. To the best of our knowledge, this is the first study to demonstrate that a significant MD/MK mismatch and heterogeneity of multiple ischemic lesions on MK in subacute ischemic stroke may represent a new expansion of an ischemic lesion or acute reinfarction, which is closely related to ND.
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Affiliation(s)
- Yue-Lin Guo
- Department of Radiology, The 2nd Affiliated Hospital, Shantou University Medical College, Shantou, 515000 Guangdong, China
| | | | - Gui-Shan Zhang
- Engineering College Shantou University, Shantou, 515000 Guangdong, China
| | - Ling-Mei Kong
- Department of Radiology, The 2nd Affiliated Hospital, Shantou University Medical College, Shantou, 515000 Guangdong, China
| | - Hai-Bing Rao
- Department of Radiology, The 2nd Affiliated Hospital, Shantou University Medical College, Shantou, 515000 Guangdong, China
| | - Wei Chen
- Department of Neurology, The 2nd Affiliated Hospital, Shantou University Medical College, Shantou, 515000 Guangdong, China
| | - Guang-Wen Wang
- Department of Neurology, The 2nd Affiliated Hospital, Shantou University Medical College, Shantou, 515000 Guangdong, China
| | - Zhi-Wei Shen
- Department of Radiology, The 2nd Affiliated Hospital, Shantou University Medical College, Shantou, 515000 Guangdong, China
| | - Wen-Bin Zheng
- Department of Radiology, The 2nd Affiliated Hospital, Shantou University Medical College, Shantou, 515000 Guangdong, China
| | - Ren-Hua Wu
- Department of Radiology, The 2nd Affiliated Hospital, Shantou University Medical College, Shantou, 515000 Guangdong, China.
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Jeon SB, Koh Y, Choi HA, Lee K. Critical care for patients with massive ischemic stroke. J Stroke 2014; 16:146-60. [PMID: 25328873 PMCID: PMC4200590 DOI: 10.5853/jos.2014.16.3.146] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 09/03/2014] [Accepted: 09/04/2014] [Indexed: 01/29/2023] Open
Abstract
Malignant cerebral edema following ischemic stroke is life threatening, as it can cause inadequate blood flow and perfusion leading to irreversible tissue hypoxia and metabolic crisis. Increased intracranial pressure and brain shift can cause herniation syndrome and finally brain death. Multiple randomized clinical trials have shown that preemptive decompressive hemicraniectomy effectively reduces mortality and morbidity in patients with malignant middle cerebral artery infarction. Another life-saving decompressive surgery is suboccipital craniectomy for patients with brainstem compression by edematous cerebellar infarction. In addition to decompressive surgery, cerebrospinal fluid drainage by ventriculostomy should be considered for patients with acute hydrocephalus following stroke. Medical treatment begins with sedation, analgesia, and general measures including ventilatory support, head elevation, maintaining a neutral neck position, and avoiding conditions associated with intracranial hypertension. Optimization of cerebral perfusion pressure and reduction of intracranial pressure should always be pursued simultaneously. Osmotherapy with mannitol is the standard treatment for intracranial hypertension, but hypertonic saline is also an effective alternative. Therapeutic hypothermia may also be considered for treatment of brain edema and intracranial hypertension, but its neuroprotective effects have not been demonstrated in stroke. Barbiturate coma therapy has been used to reduce metabolic demand, but has become less popular because of its systemic adverse effects. Furthermore, general medical care is critical because of the complex interactions between the brain and other organ systems. Some challenging aspects of critical care, including ventilator support, sedation and analgesia, and performing neurological examinations in the setting of a minimal stimulation protocol, are addressed in this review.
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Affiliation(s)
- Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - H Alex Choi
- Departments of Neurology and Neurosurgery, The University of Texas Medical School at Houston, Houston, Texas, USA
| | - Kiwon Lee
- Departments of Neurology and Neurosurgery, The University of Texas Medical School at Houston, Houston, Texas, USA
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