Long-Term Outcome After Surgical Treatment for Space-Occupying Cerebellar Infarction

Abstract

Background and Purpose-Surgical management of space-occupying cerebellar infarction is still controversial. Data on long-term outcome are lacking. The objective of this study was (1) to evaluate outcome after at least 3 years poststroke in patients with space-occupying cerebellar infarction treated by ventriculostomy/extraventricular drainage (EVD) or suboccipital decompressive craniectomy (SDC), or both, and (2) to determine predicting factors for outcome. Methods-In this retrospective single-center study 56 consecutive patients with acute space-occupying cerebellar infarction treated surgically between 1996 and 2005 were included. Baseline data included clinical findings, Glasgow Coma Scale on admission and before surgery, NIHSS on admission, mass effects on neuroimaging, and surgical treatment strategies. Modified Rankin Scale, NIHSS, and Scale for the Assessment and Rating of Ataxia were used to assess outcome. Results-39.3% of patients had died, 51.8% had a mRS Յ3, 35.7% had a mRS Յ2, 28.6% had a mRS Յ1. There were no significant differences in survival between treatment groups. In multivariate analysis age and mRS score at discharge were the most evident independent predictors for outcome. Conclusions-So far this is the largest study on long-term outcome after space-occupying cerebellar infarction.

Space-occupying cerebellar infarction: complications, treatment, and outcome

“…15,19,41,47,51,56,58,75,84,91,94,104 So far it is not clear which factors promote edema formation after stroke. In addition to infarct size, other factors such as hemorrhagic transformation and inadequate collateral blood flow may be involved.…”

“…Some neurosurgeons also remove necrotic cerebellar tissue to create extra space within the posterior fossa and reduce development of cytotoxic edema. 51,56,91 In cerebellar stroke, there is no general agreement about the optimal time to initiate surgery or about what factors would mandate proceeding to surgery. Local surgery protocols differ greatly, and the questions of whether and when ventriculostomy or SDC should be performed and whether surgery should be performed in a single intervention, in combination, or in a stepwise approach remain unanswered.…”

“…There is some evidence that higher age is associated with poorer outcome. 47,56 The summary tables should be interpreted with caution as most of the studies investigating outcome suffer from the limitations of retrospective data collection, lack of control groups, single-center or small multicenter (oligocenter) experience, limited size of patient cohorts, and other selection biases (Table 3). Most importantly, there were marked imbalances between treatment groups; i.e., patients with pronounced mass effect on CT and impaired level of consciousness were more likely to be treated with SDC and additional EVD.…”

“…There are only 3 studies on long-term outcome that include larger numbers of patients with follow-up of more than 1 year. 56,91,115 In one of these studies, a retrospective single-center case series on SDC plus EVD and strokectomy (removal of necrotic tissue) in 32 patients with expansive unilateral cerebellar infarcts, a low mortality rate (32%) and a high rate of independent outcome (53% mRS score 0-2) was found in long-term survivors. 115 In contrast, the 2 other studies, which included 108 patients treated with different strategies, reported a lower long-term survival rate of 60%.…”

Acute ischemic stroke in the ICU: to admit or not to admit?

“…in the treatment and prevention of aspiration pneumonia due to temporal loss of bulbar function, occurring in 37-78 % of stroke patients [21]. Large MCA strokes who may require decompressive craniectomy, regardless of their age [3,4], and spaceoccupying cerebellar infarctions accessible to a prompt surgical decompression [22] are a clear indication for ICU admission. In some cases, the management of blood pressure, or seizures, might necessitate an ICU admission.…”