Suboccipital Decompressive Craniectomy for Cerebellar Infarction

Swollen cerebral and cerebellar infarcts are critical conditions that warrant immediate, specialized neurointensive care and often neurosurgical intervention. Decompressive craniectomy is a necessary option in many patients. Selected patients may benefit greatly from such an approach, and although disabled, they may be functionally independent 1).

In a retrospective, single-center study, of 34 consecutive patients necrosectomy appears to be a suitable alternative to Suboccipital Decompressive Craniectomy for Cerebellar Infarction, achieving comparable mortality and functional outcomes. Further trials are necessary to evaluate which surgical technique is more beneficial in the setting of Cerebellar Infarction 2).

Unlike the situation with supratentorial masses causing herniation, there are several reports of patients in a deep coma from direct brainstem compression who were operated upon quickly and made useful recovery.

The operation of choice is a suboccipital decompression to include enlargement of the foramen magnum. The dura is then opened and the infarcted cerebellar tissue usually exudes “like toothpaste” and is easily aspirated. Avoid using ventricular drainage alone as this may cause upward cerebellar herniation and does not relieve the direct brainstem compression.

A decompressive craniectomy is a necessary option in many patients. Selected patients may benefit greatly from such an approach, and although disabled, they may be functionally independent 3) 4).

Suboccipital decompressive craniectomy (SDC) for cerebellar infarction has been traditionally performed with minimal high-quality evidence. The aim of a systematic review and meta-analysis was to investigate the impact of SDC on functional outcomes, mortality, and adverse events in patients with cerebellar infarcts.

A systematic review and meta-analysis in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and MetaAnalyses) guidelines. The primary outcome was the proportion of patients with moderate-severe disability after SDC. Secondary outcomes included mortality and adverse events. A sensitivity analysis was conducted to examine the roles of age, preoperative neurologic status, external ventricular drain insertion, and debridement of infarcted tissue on SDC outcomes.

Eleven studies (with 283 patients) met the inclusion criteria. The pooled event rate for moderate-severe disability was 28% (95% confidence interval [CI], 20%-37%) and for mortality, it was 20% (95% CI, 12%-31%). The estimated overall rate of adverse events for SDC was 23% (95% CI, 14%-35%).Sensitivity analysis found less mortality with mean age <60 years, higher rates of concomitant external ventricular drain insertion, and debridement of infarcted tissue. Several factors were identified for heterogeneity between studies, including follow-up time, outcomes scale, extent of infarction, and other neuroimaging features.

The best available evidence for SDC is based on retrospective observational studies. SDC for cerebellar infarction is associated with better outcomes compared with decompressive surgery for hemispheric infarctions. Lack of standardized reporting methods for SDC is a considerable drawback to the development of a better understanding of the impact of this surgery on patient outcomes 5).

All patients treated with SDC due to space-occupying cerebellar infarction between January 2009 and October 2015 were included in the study. Data was retrospectively collected from patient records, CT/MRI scans and surgical protocols. Long-term functional outcome was determined by the modified Rankin Scale (mRS) and mRS ≥ 4 was defined as unfavorable outcome.

Twenty-two patients (16 male, 6 female) were included in the study. Median age was 53 years. Nine patients were treated with external ventricular drainage as an initial treatment attempt prior to SDC. Median time from symptom onset (stroke ictus) to initiation of the SDC surgery was 48 h (IQR 28-99 hours) and median GCS before SDC was 8 (IQR 5-10). At follow up, median mRS was 3 (IQR 2-6). Outcome was favorable (mRS 0-3) in 12 patients and unfavorable in 10 (3 with major disability, 7 dead). Brainstem infarction and bilateral cerebellar infarction were associated with unfavorable outcome.

In this small study, functional long-term outcome in patients with space-occupying cerebellar infarction treated by SDC was acceptable and comparable to previously published results (favorable outcome in 54% of patients). Brainstem infarction and bilateral cerebellar infarction were associated with unfavorable outcome 6).

From October 2006 to June 2017, 14 consecutive patients (12 males, 2 females; age, 42–84 years; mean age ± standard deviation, 65 ± 12 years) admitted to our hospital and underwent DSC under at an admission or clinical course in hospitalization following inclusion criteria: 1) level of consciousness below Glasgow Coma Scale (GCS) 13 or 2) brainstem compression and/or obstructive hydrocephalus due to brain edema by cerebellar infarction. Ventricular drainage was performed simultaneously or later by surgeons’ decision. Results: After 90 days, 12 of the 14 patients survived (85.7%), 10 (71.4%) were independent (modified Rankin scale [mRS] ≤ 2) and four (28.6%) were completely dependent or dead. Comparison between good and poor prognosis demonstrated that the factors affecting prognosis were lesions other than cerebellar infarction (p<0.01) and obstructive hydrocephalus (p<0.05). Conclusion: Early DSC for cerebellar infarction may be advisable for cerebellar infarction in patients with GCS 13 or worse before advancement of hydrocephalus. Poor prognosis is inevitable in patients causing otherinfarcts other than cerebellum and patients who have already accompanied obstructive hydrocephalus at the time of surgery 7).

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 8).

Mostofi retrospectively analyzed the clinical features, and imaging studies of 53 patients with MICI who had been treated by surgery or conservative treatment between January 2000 and December 2008 at the Department of Neurosurgery of the general hospital of Fort de France in Martinique. A total of 25 patients underwent surgery and 28 were treated medically.

Results: The results show significantly better outcomes in the operated patients compared with the patients treated medically; Operated comatose patients demonstrated significant improvement in their Glasgow coma score (GCS) score with only two deaths. Whereas, nonoperated comatose patients lost points in their GCS with four deaths.

Conclusion: The results of our study suggest that surgery may be an effective procedure and quite helpful for MICI in majority of cases 9).

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 > or =4; hazard ratio: 9.1; P=0.001). 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 10).

In a 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 < or =3, 35.7% had a mRS < or =2, 28.6% had a mRS < or =1. 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. The value of different treatment strategies and prognostic factors for patient selection remain unclear and should be evaluated in larger prospective case-series or registries. To investigate the issue of preventive SDC randomized trials are needed 11).

A report presents the treatment of 151 patients with cerebellar infarction, 98 men (65%) and 53 women (35%), mean age 62.4 years old. Occlusive hydrocephalus was diagnosed in 7.9% of the patients associated with an extensive cerebellar infarction and in all 11 surgical patients (7.2%). Four patients underwent an external ventricular drainage with 3 deaths (75%) and 7 underwent a decompressive suboccipital craniectomy with 2 deaths (28.5%). Mortality of the clinical group was 15 patients (10.7%). Vertigo, vomiting, Romberg sign and dysmetria were the signs and symptoms of cerebellar involvement that were most frequently observed. Cerebellar infarction from embolism after cardiovascular surgery occurred in 57 patients (37.7%). Cerebellar infarction, as an isolated fact, occurred in 59 patients (39%) and cerebellar plus infarction in other regions occurred in 92 patients (61%). Magnetic resonance image was the best diagnostic form for cerebellar lesions, however computerized tomography could show cerebellar infarction in 68 patients (78%) 12).

In a retrospective study 100 consecutive patients with cerebellar apoplexy were evaluated with regard to presenting symptoms, diagnostic and therapeutic strategies according to changes in the clinical condition of the patients. The results of decompressive suboccipital craniectomy in patients with a cerebellar infarction is also evaluated in this retrospective study as the valency from use the Glasgow-Coma-Score as prognostical factor and monitoring instrument in patients with a cerebellar stroke. Different therapeutic modalities were critically analyzed. Outcome was sgnificantly influenced by age (p = 0.003), localisation and size of the lesion (p = 0.004), space-occupying character on computed tomography (p < 0.001), the progressive appearance of brainstem dysfunction and reduction of the level of consciousness as measured with the Glasgow Coma Scale (p < 0.001). We were able to show that the GCS is a valid instrument for the evaluation of the clinical course of patients with cerebellar stroke since a statistically significant relationship exists between the GCS prior to surgical intervention and outcome. In patient with a GCS < 12 a reduction of mortality by 15% was obtained by surgical intervention and the outcome as measured by the GOS was significantly improved 13)

10 patients with progressive neurological deterioration due to massive cerebellar infarctions. Computerized tomography scans confirmed obstructive hydrocephalus and brain stem compression. All 10 patients (seven men, three women; mean age, 59 years) were treated by external ventricular drainage and decompressive suboccipital craniectomy. After discharge from the hospital, they were followed up (23-101 months) and their functional independence was evaluated by the Barthel Index. The condition of three patients with brain-stem infarction had deteriorated despite decompressive surgery. Two of these died during the acute stage and one because severely disabled. The remaining seven patients showed neurological improvement during the postoperative period. Four patients with preoperative Japan Coma Scale of 100 returned to their previous jobs within the follow-up period and three patients with preoperative Japan Coma Scale of 200 required some assistance in daily activities. It is suggested that decompressive surgery may be beneficial for massive cerebellar infarction. The postoperative prognosis depends mainly on the presence or absence of coexisting brain-stem infarction. It is possible that, without brain-stem infarction, patients who remained in a “dependent” state may have recovered better if they had been operated on earlier 14).

Of 52 patients with space-occupying cerebellar infarction defined by computed tomographic criteria were reevaluated with regard to clinical course, etiology, therapeutic management, mortality, and functional outcome.

In most cases clinical deterioration started on the third day after stroke, and a comatose state was reached within 24 hours. Sixteen patients were treated medically, and 30 by suboccipital craniectomy (22 plus ventriculostomy, 12 plus tonsillectomy). Ten patients primarily had ventriculostomy, which in 4 patients was supplemented by craniotomy because of continuing deterioration. Twenty-nine patients made a good recovery, 15 remained disabled, and 8 died. Even comatose patients had a 38% chance of a good recovery with decompressive surgery. Age older than 60 years (P = .0043) and probably initial brain stem signs (P = .0816) and a late clinical stage (P = .0893) were linked with a fatal or disabling outcome.

Decompressive surgery should be the treatment of choice for massive cerebellar infarction causing progressive brain stem signs or impairment of consciousness 15).

11 patients (seven men, four women; mean age, 54 years) were treated with suboccipital craniectomy for decompression and temporary ventriculostomy for cerebrospinal fluid pressure monitoring and drainage.

Seven patients demonstrated neurological improvement on the first postoperative day. Two patients returned to their previous jobs 3 months after surgery. The Barthel Index indicated that six individuals were functioning with minimal assistance within a follow-up period of 16-60 months. The remaining three were functionally dependent. No mortality was noted in this series.

These results suggest that decompressive suboccipital craniectomy may be an effective, lifesaving procedure for malignant cerebellar edema after a large infarction 16).

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