Controversy of Surgical Treatment for Severe Cerebellar Infarction

Kudo, Hiroshi; Kawaguchi, Tetsuro; Minami, Hiroaki; Kuwamura, Keiichi; Miyata, Mariko; Kohmura, Eiji

doi:10.1016/j.jstrokecerebrovasdis.2007.09.001

Cited by 41 publications

(24 citation statements)

References 22 publications

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“…Despite this, mortality in our study was comparable to previous studies with up to 20 patients, in which early mortality reached 0% to 50%. 10,14,15 The majority of patients (70%) were referred from community hospitals before SDC, many of them with the clear prospective to receive SDC in the case of clinical deterioration. This referral pattern may have influenced the rate of patients treated by SDC with respect to all admitted patients with acute cerebellar infarction.…”

Section: Discussionmentioning

confidence: 99%

“…1,[13][14][15]28 In our population, the standardized surgical protocol included extensive bilateral SDC and evacuation of necrotic tissue with the aim to create maximum space for progressing edema. Because SDC was the predefined mandatory surgical approach, our study cannot provide evidence on any superiority of SDC or insertion of an EVD as the primary surgical procedure.…”

Section: Discussionmentioning

confidence: 99%

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Long-Term Outcome After Suboccipital Decompressive Craniectomy for Malignant Cerebellar Infarction

Pfefferkorn

Eppinger

Linn

et al. 2009

Stroke

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Background and Purpose-Suboccipital decompressive craniectomy (SDC) is a life-saving intervention for patients with malignant cerebellar infarction. However, long-term outcome has not been systematically analyzed. Methods-In this monocentric retrospective study we analyzed mortality, long-term functional outcome, and quality of life of all consecutive patients that were treated by SDC for malignant cerebellar infarction in our institution between 1995 and 2006. Results-A total of 57 patients were identified. All of them were treated by bilateral SDC. An external ventricular drainage was inserted in 82%, necrotic tissue was evacuated in 56% of patients. There were no fatal procedural complications. Five patients were lost for follow-up. In the remaining 52 patients, the mean follow-up interval was 4.7 years (1 to 11 years). Within the first 6 months after surgery 16 of 57 patients (28%) had died. At follow-up, 21 of 52 patients (40%) had died and 4 patients (8%) lived with major disability (mRS 4 or 5). Twenty-one patients (40%) lived functionally independent (mRS 0 to 2). The presence of additional brain stem infarction was associated with poor outcome (mRS Ն4; hazard ratio: 9.1; Pϭ0.001). Quality of life in survivors was moderately lower than in healthy controls. Conclusions-SDC is a safe procedure in patients with malignant cerebellar infarction. Infarct-but not procedure-related early mortality is substantial. Long-term outcome in survivors is acceptable, particularly in the absence of brain stem infarction.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Long-Term Outcome After Suboccipital Decompressive Craniectomy for Malignant Cerebellar Infarction

Pfefferkorn

Eppinger

Linn

et al. 2009

Stroke

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“…In this study, however, the frequency of EVD placement (50%; 14 of the 28 patients in group A) was lower compared with previous reports. [10][11][12][13][14]16,22 Jüttler et al 16 performed EVD in 48 (85.7%) of 56 patients. Among them, 9 patients were treated by EVD alone.…”

Section: Strokementioning

confidence: 99%

Preventive Suboccipital Decompressive Craniectomy for Cerebellar Infarction

Kim

Park

Song

et al. 2016

Stroke

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Background and Purpose-No evidence is available on the benefits of preventive suboccipital decompressive craniectomy (SDC) for patients with cerebellar infarction. The purpose of this matched case-control study was to investigate whether preventive SDC was associated with good clinical outcomes in patients with cerebellar infarction and to evaluate its predisposing factors. Methods-Between March 2007 and September 2015, 28 patients underwent preventive SDC. We performed propensity score matching to establish a proper control group among 721 patients with cerebellar infarction during the same period. Group A (n=28) consists of those who underwent preventive SDC, and group B (n=56) consists of those who did not undergo preventive SDC. We analyzed and compared clinical outcomes between groups. Results-Clinical outcomes were better in group A than in group B at discharge (P=0.048) and 12-month follow-up (P=0.030).Group B had more deaths within 12 months than group A (log-rank, P<0.05). Logistic regression analysis showed that preventive SDC (odds ratio, 4.815; P=0.009) and the absence of brain stem infarction (odds ratio, 2.862; P=0.033) were independently associated with favorable outcomes (modified Rankin Scale score of 0-2) at 12-month follow-up. Conclusions-Favorable clinical outcomes including overall survival can be expected after preventive SDC in patients with a volume ratio between 0.25 and 0.33 and the absence of brain stem infarction. Among these patients, preventive SDC might be better than the best medical treatment alone.

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“…44,47,51,57,68,69,91,112,115 Today most neurosurgeons and neurologists believe that the clinical outcome of patients with space-occupying cerebellar stroke who have undergone successful life-saving surgery is usually good irrespective of other prognostic factors. This opinion is reflected by current guidelines and recommendations.…”

Section: Outcomementioning

confidence: 99%

“…12,41,94 Although ventriculostomy alone is sometimes considered dangerous due to possible upward herniation, this risk seems rather small. 15,41,47,58,68,69,94,116 Patients with signs of quadrigeminal cistern and/or brainstem compression should undergo immediate SDC combined with or followed by EVD if they have signs of hydrocephalus that do not resolve after SDC. 12,41,94 Some authors regard the combined approach of ventriculostomy and decompressive surgery as the first choice for patients with occlusive hydrocephalus.…”

Section: Suggested Treatment Algorithmmentioning

confidence: 99%

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

Neugebauer

Witsch

Zweckberger

et al. 2013

FOC

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Space-occupying brain edema is a frequent and one of the most dreaded complications in ischemic cerebellar stroke. Because the tight posterior fossa provides little compensating space, any space-occupying lesion can lead to life-threatening complications through brainstem compression or compression of the fourth ventricle and subsequent hydrocephalus, both of which may portend transtentorial/transforaminal herniation. Patients with large cerebellar infarcts should be treated and monitored very early on in an experienced stroke unit or (neuro)intensive care unit. The general treatment of ischemic cerebellar infarction does not differ from that of supratentorial ischemic strokes. Treatment strategies for space-occupying edema include pharmacological antiedema and intracranial pressure–lowering therapies, ventricular drainage by means of an extraventricular drain, and suboccipital decompressive surgery, with or without resection of necrotic tissue. Timely escalation of treatment is crucial and should be guided by clinical and neuroradiological rationales. Patients in a coma after hydrocephalus and/or local brainstem compression may also benefit from more aggressive surgical treatment, as long as the conditions are reversible. Contrary to the general belief that outcome in survivors of space-occupying cerebellar stroke is usually good, recent studies suggest that for many of these patients, the long-term outcome is not good. In particular, advanced age and additional brainstem infarction seem to be predictors for poor outcome. Further trials are necessary to investigate these findings systematically and provide better selection criteria to help guide decisions about surgical therapies, which should always be carried out in close cooperation among neurointensive care physicians, neurologists, and neurosurgeons.

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Controversy of Surgical Treatment for Severe Cerebellar Infarction

Cited by 41 publications

References 22 publications

Long-Term Outcome After Suboccipital Decompressive Craniectomy for Malignant Cerebellar Infarction

Long-Term Outcome After Suboccipital Decompressive Craniectomy for Malignant Cerebellar Infarction

Preventive Suboccipital Decompressive Craniectomy for Cerebellar Infarction

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

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