Predicting Surgical Intervention in Cerebellar Stroke: A Quantitative Retrospective Analysis

Endoscopic Cerebellar Necrosectomy for Space-occupying Cerebellar Infarction: A Case Report

Suboccipital decompressive craniectomy with or without resection of necrosis is the preferred treatment for space-occupying cerebellar infarctions with neurological deterioration due to brainstem compression and obstructive hydrocephalus. We herein present our experience with treating space-occupying cerebellar infarctions successfully using endoscopic necrosectomy. A total of 27 patients were admitted to our hospital due to cerebellar infarctions between April 2021 and November 2023. Four patients required surgical interventions due to a drop in consciousness level or compression of the fourth ventricle and brainstem with acute hydrocephalus confirmed by a computed tomography (CT) scan. Three patients were performed endoscopic necrosectomy through a burr hole in a supine-lateral position. Removing most of the necrotic tissue was possible, resulting in early decompression of the fourth ventricle and brainstem. Endoscopic necrosectomy is less invasive than suboccipital decompressive craniectomy. An endoscopic necrosectomy can be performed for patients with unstable health conditions in a supine-lateral position. Therefore, endoscopic necrosectomy might be an effective method for treating patients with space-occupying cerebellar infarctions and poor general condition, although an objective evaluation of the extent and degree of removal is needed.

Functional and Mortality Outcomes with Medical and Surgical Therapy in Malignant Posterior Circulation Infarcts: A Systematic Review

BACKGROUND

There remains uncertainty regarding optimal definitive management for malignant posterior circulation infarcts (MPCI). While guidelines recommend neurosurgery for malignant cerebellar infarcts that are refractory to medical therapy, concerns exist about the functional outcome and quality of life after decompressive surgery.

OBJECTIVE

This study aims to evaluate the outcomes of surgical intervention compared to medical therapy in MPCI.

METHODS

In this systematic review, MEDLINE, Embase and Cochrane databases were searched from inception until 2 April 2021. Studies were included if they involved posterior circulation strokes treated with neurosurgical intervention and reported mortality and functional outcome data. Data were collected according to PRISMA guidelines.

RESULTS

The search yielded 6677 studies, of which 31 studies (comprising 723 patients) were included for analysis. From the included studies, we found that surgical therapy led to significant differences in mortality and functional outcomes in patients with severe disease. Neurological decline and radiological criteria were often used to decide the timing for surgical intervention, as there is currently limited evidence for preventative neurosurgery. There is also limited evidence for the superiority of one surgical modality over another.

CONCLUSION

For patients with MPCI who are clinically stable at the time of presentation, in terms of mortality and functional outcome, surgical therapy appears to be equivocal to medical therapy. Reliable evidence is lacking, and further prospective studies are rendered.

Predictors of clinical outcomes in space-occupying cerebellar infarction undergoing suboccipital decompressive craniectomy

Introduction

Despite current clinical guidelines recommending suboccipital decompressive craniectomy (SDC) in cerebellar infarction when patients present with neurological deterioration, the precise definition of neurological deterioration remains unclear and accurate timing of SDC can be challenging. The current study aimed at characterizing whether clinical outcomes can be predicted by the GCS score immediately prior to SDC and whether higher GCS scores are associated with better clinical outcomes.

Methods

In a single-center, retrospective analysis of 51 patients treated with SDC for space-occupying cerebellar infarction, clinical and imaging data were evaluated at the time points of symptom onset, hospital admission, and preoperatively. Clinical outcomes were measured by the mRS. Preoperative GCS scores were stratified into three groups (GCS, 3-8, 9-11, and 12-15). Univariate and multivariate Cox regression analyses were performed using clinical and radiological parameters as predictors of clinical outcomes.

Results

In cox regression analysis GCS scores of 12-15 at surgery were significant predictors of positive clinical outcomes (mRS, 1-2). For GCS scores of 3-8 and 9-11, no significant increase in proportional hazard ratios was observed. Negative clinical outcomes (mRS, 3-6) were associated with infarct volume above 6.0 cm³, tonsillar herniation, brainstem compression, and a preoperative GCS score of 3-8 [HR, 2.386 (CI, 1.160-4.906); p = 0.018].

Conclusion

Our preliminary findings suggest that SDC should be considered in patients with infarct volumes above 6.0 cm³ and with GCS between 12 and 15, as these patients may show better long-term outcomes than those in whom surgery is delayed until a GCS score below 11.