Cerebellar Necrosectomy Instead of Suboccipital Decompression: A Suitable Alternative for Patients with Space-Occupying Cerebellar Infarction

Hernández-Durán, Silvia; Wolfert, Christina; Rohde, Veit

doi:10.1016/j.wneu.2020.09.067

Cited by 8 publications

(14 citation statements)

References 27 publications

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“…Complications were not uncommon, with 12.2% (6/49) of our patients requiring revision surgery, including four cases with CSF fistulas (8.2%), and two cases (4.1%) were treated with antibiotics for meningitis. Similar figures have also been reported by others (revision surgeries: 7–12% ( 11 , 29 ), surgical site infections: 4–6% ( 8 , 29 ), CSF fistulas: 4–9% ( 8 , 11 , 29 ).…”

Section: Discussionsupporting

confidence: 90%

“…We report 49 cases. This figure is not very large (even though it compares favorably with the recent literature ( 11 , 19 , 29 , 30 ). Follow-up data were incomplete.…”

Section: Discussionsupporting

confidence: 78%

“…Of note, all the in-hospital deaths in our cohort were due to dismal neurological conditions following cerebellar stroke or an underlying disease that had caused the infarction. Published mortality rates are in the 20–25% range ( 11 , 19 , 29 , 30 ). Kim et al reported unusually good mortality figures (4%) in their series of 28 surgical cases undergoing what these authors defined as preventive surgery ( 11 ).…”

Section: Discussionmentioning

confidence: 99%

“…Functional outcomes after posterior fossa decompression surgery are generally not good either. The more recent studies report early mRS 0–3 outcomes in only 24–34% ( 19 , 29 ) (cf. 36.7% in our cohort).…”

Section: Discussionmentioning

confidence: 99%

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Clinical and Computerized Volumetric Analysis of Posterior Fossa Decompression for Space-Occupying Cerebellar Infarction

Fernandes

Ridwan²,

Greeve

et al. 2022

Front. Neurol.

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Background and PurposeSurgical decompression of the posterior fossa is often performed in cases with a space-occupying cerebellar infarction to prevent coma and death. In this study, we analyzed our institutional experience with this condition. We specifically attempted to address timing issues and investigated the role of cerebellar necrosectomy using imaging data and conducting volumetric analyses.MethodsWe retrospectively studied pertinent clinical and imaging data, including computerized volumetric analyses (preoperative/postoperative infarction volume, necrosectomy volume, and posterior fossa volume), from all 49 patients who underwent posterior fossa decompression surgery for cerebellar infarction in our department from January 2012 to January 2021.ResultsThirty-five (71%) patients had a Glasgow Coma Scale (GCS) of 14–15 at admission vs. only 14 (29%) before vs. 41 (84%) following surgery. Seven (14%) patients had preventive surgery (initial GCS 14–15, preoperative GCS change ≤ 1). Only 18 (37%) patients had an mRS score of 0–3 at discharge. Estimated overall survival was 70.5% at 1 year. Interestingly, 18/20 (90%) surviving cases had a modified Rankin Scale (mRS) outcome of 0–3 (mRS 0–2: 12/20 [60%]) 1 year after surgery. Surgical timing, including preventive surgery and mass effect of the infarct, in the posterior fossa assessed semi-quantitatively (Kirollos grade) and with volumetric parameters that were not predictive of the patients' (functional) outcomes.ConclusionPosterior fossa decompression for cerebellar infarction is a life-saving procedure, but rapid recovery of the GCS after surgery does not necessarily translate into good functional outcome. Many patients died during follow-up, but long-term mRS outcomes of 4–5 are rare. Surgery should probably aim primarily at pressure relief, and our clinical as well as volumetric data suggest that the impact of removing an infarcted tissue may be limited. It is presumably relatively safe to initially withhold surgery in cases with a GCS of 14–15.

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Section: Discussionsupporting

confidence: 90%

“…We report 49 cases. This figure is not very large (even though it compares favorably with the recent literature ( 11 , 19 , 29 , 30 ). Follow-up data were incomplete.…”

Section: Discussionsupporting

confidence: 78%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Clinical and Computerized Volumetric Analysis of Posterior Fossa Decompression for Space-Occupying Cerebellar Infarction

Fernandes

Ridwan²,

Greeve

et al. 2022

Front. Neurol.

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“…When compared with pooled results from a meta-analysis [11] on SDC in cerebellar infarcts, Hernández-Durán et al [30] found that there was no signi cant difference in outcomes or deaths between patients undergoing necrosectomy via osteoplastic craniotomy and patients undergoing SDC.…”

Section: Choice Of Surgical Interventionmentioning

confidence: 99%

Functional and mortality outcomes with medical and surgical therapy in malignant posterior circulation infarcts: A systematic review

Lim

Lin

Tan³

et al. 2022

Preprint

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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 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 2nd 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 6,677 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 was 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, in terms of mortality and functional outcome, surgical therapy appears to be equivocal to medical therapy, except in patients with severe disease. Reliable evidence is lacking and further prospective studies are rendered.

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Functional Outcomes in Conservatively vs Surgically Treated Cerebellar Infarcts

Won,

Hernández-Durán,

Behmanesh

et al. 2024

JAMA Neurol

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ImportanceAccording to the current American Heart Association/American Stroke Association guidelines, decompressive surgery is indicated in patients with cerebellar infarcts that demonstrate severe cerebellar swelling. However, there is no universal definition of swelling and/or infarct volume(s) available to support a decision for surgery.ObjectiveTo evaluate functional outcomes in surgically compared with conservatively managed patients with cerebellar infarcts.Design, Setting, and ParticipantsIn this retrospective multicenter cohort study, patients with cerebellar infarcts treated at 5 tertiary referral hospitals or stroke centers within Germany between 2008 and 2021 were included. Data were analyzed from November 2020 to November 2023.ExposuresSurgical treatment (ie, posterior fossa decompression plus standard of care) vs conservative management (ie, medical standard of care).Main Outcomes and MeasuresThe primary outcome examined was functional status evaluated by the modified Rankin Scale (mRS) at discharge and 1-year follow-up. Secondary outcomes included the predicted probabilities for favorable outcome (mRS score of 0 to 3) stratified by infarct volumes or Glasgow Coma Scale score at admission and treatment modality. Analyses included propensity score matching, with adjustments for age, sex, Glasgow Coma Scale score at admission, brainstem involvement, and infarct volume.ResultsOf 531 included patients with cerebellar infarcts, 301 (57%) were male, and the mean (SD) age was 68 (14.4) years. After propensity score matching, a total of 71 patients received surgical treatment and 71 patients conservative treatment. There was no significant difference in favorable outcomes (ie, mRS score of 0 to 3) at discharge for those treated surgically vs conservatively (47 [66%] vs 45 [65%]; odds ratio, 1.1; 95% CI, 0.5-2.2; P &gt; .99) or at follow-up (35 [73%] vs 33 [61%]; odds ratio, 1.8; 95% CI, 0.7-4.2; P &gt; .99). In patients with cerebellar infarct volumes of 35 mL or greater, surgical treatment was associated with a significant improvement in favorable outcomes at 1-year follow-up (38 [61%] vs 3 [25%]; odds ratio, 4.8; 95% CI, 1.2-19.3; P = .03), while conservative treatment was associated with favorable outcomes at 1-year follow-up in patients with infarct volumes of less than 25 mL (2 [34%] vs 218 [74%]; odds ratio, 0.2; 95% CI, 0-1.0; P = .047).Conclusions and RelevanceOverall, surgery was not associated with improved outcomes compared with conservative management in patients with cerebellar infarcts. However, when stratifying based on infarct volume, surgical treatment appeared to be beneficial in patients with larger infarct volumes, while conservative management appeared favorable in patients with smaller infarct volumes.

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Cerebellar Necrosectomy Instead of Suboccipital Decompression: A Suitable Alternative for Patients with Space-Occupying Cerebellar Infarction

Cited by 8 publications

References 27 publications

Clinical and Computerized Volumetric Analysis of Posterior Fossa Decompression for Space-Occupying Cerebellar Infarction

Clinical and Computerized Volumetric Analysis of Posterior Fossa Decompression for Space-Occupying Cerebellar Infarction

Functional and mortality outcomes with medical and surgical therapy in malignant posterior circulation infarcts: A systematic review

Functional Outcomes in Conservatively vs Surgically Treated Cerebellar Infarcts

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