====== Suboccipital Decompressive Craniectomy for cerebellar infarction ====== {{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1TgNO0ldD-bmX_dB_UObaAxTJWAoSfne5AVu4n7-b4F6grxgud/?limit=15&utm_campaign=pubmed-2&fc=20240226163922}} Unlike the situation with [[supratentorial]] [[mass]]es 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. ===== Guidelines ===== [[Guidelines]] from the [[American Heart Association]]/Stroke Council’s Scientific Statement Oversight Committee from 2014 recommended [[suboccipital decompressive craniectomy]] (SDC) with dural expansion to be performed in deteriorating patients with cerebellar infarction failing maximal medical therapy ((Wijdicks EF, Sheth KN, Carter BS, Greer DM, Kasner SE, Kimberly WT, Schwab S, Smith EE, Tamargo RJ, Wintermark M; [[American Heart Association]] [[Stroke Council]]. [[Recommendation]]s for the [[management]] of cerebral and [[cerebellar infarction]] with [[swelling]]: a statement for [[healthcare]] [[professional]]s from the [[American Heart Association]]/[[American Stroke Association]]. Stroke. 2014 Apr;45(4):1222-38. doi: 10.1161/01.str.0000441965.15164.d6. Epub 2014 Jan 30. PubMed PMID: 24481970.)). However, no good-quality evidence is available to support this surgical practice, and the surgical timing and technique both remain controversial ((Hernández-Durán S, Wolfert C, Rohde V, Mielke D. Cerebellar Necrosectomy Instead of Suboccipital Decompression: A Suitable Alternative for Patients with Space-Occupying cerebellar infarction. World Neurosurg. 2020 Dec;144:e723-e733. doi: 10.1016/j.wneu.2020.09.067. Epub 2020 Sep 22. PMID: 32977029.)). ===== Evidence ===== The evidence favoring suboccipital decompressive craniectomy in space-occupying [[cerebellar infarction]]s stems predominantly from retrospective, monocentric, uncontrolled studies. ((Neugebauer H, Witsch J, Zweckberger K, Jüttler E. Space-occupying cerebellar infarction: complications, treatment, and outcome. Neurosurg Focus. 2013 May;34(5):E8. doi: 10.3171/2013.2.FOCUS12363. PMID: 23634927.)). ---- Large multicenter RCTs are lacking for this situation probably due to the well-known devastating effects of [[brainstem compression]] and [[hydrocephalus]]. ===== Timing ===== Criteria for patient selection and the timing of the operation are not yet established, although there are several reports that DSC is effective ---- For Suyama et al. early [[suboccipital decompressive craniectomy]] should be considered for treating [[cerebellar infarction]] in patients with [[GCS]] 13 or worse. A poor prognosis is inevitable in patients whose [[infarction]] is combined with other locations than the [[cerebellum]] but in those who already have [[obstructive hydrocephalus]] at the time of surgery ((Suyama Y, Wakabayashi S, Aihara H, Ebiko Y, Kajikawa H, Nakahara I. Evaluation of clinical significance of decompressive suboccipital craniectomy on the prognosis of cerebellar infarction. Fujita Med J. 2019;5(1):21-24. doi: 10.20407/fmj.2018-010. Epub 2018 Dec 6. PMID: 35111496; PMCID: PMC8766232.)). ===== Technique ===== {{ ::suboccipital_craniectomy.jpg?400|}} The operation of choice is a [[suboccipital decompression]] to include enlargement of the [[foramen magnum]]. The dura is then opened and the [[cerebellar infarction]] [[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]]. ---- The patient is positioned [[prone]] on [[chest roll]]s with the [[head]] in a [[Mayfield]] head-holder or in a [[horseshoe headrest]]. Flex the [[neck]] to open the interspace between the [[occiput]] and posterior arch of [[C1]]. The [[shoulder]]s is retracted inferiorly with [[adhesive tape]]. A midline [[skin incision]] from [[inion]] to ≈ [[C2]] [[spinous process]] is made. Open the [[dura]] in a “Y” shaped incision, and excise the triangular top flap. ---- Necrosectomy appears to be a suitable alternative, achieving comparable mortality and functional outcomes. Further trials are necessary to evaluate which surgical technique is more beneficial ((Hernández-Durán S, Wolfert C, Rohde V, Mielke D. Cerebellar Necrosectomy Instead of Suboccipital Decompression: A Suitable Alternative for Patients with Space-Occupying cerebellar infarction. World Neurosurg. 2020 Dec;144:e723-e733. doi: 10.1016/j.wneu.2020.09.067. Epub 2020 Sep 22. PMID: 32977029.)). ===== Systematic Review and Meta-Analysis ===== [[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]] from the [[UBC Hospital]], [[Vancouver]], was to investigate the impact of SDC on [[functional outcome]]s, [[mortality]], and [[adverse event]]s in patients with [[cerebellar infarction]]s. A [[systematic review]] and [[meta-analysis]] in accordance with the [[PRISMA]] ([[Preferred Reporting Items for Systematic Reviews and MetaAnalyses]]) [[guideline]]s. The [[primary outcome]] was the proportion of patients with a moderate-severe disability after SDC. [[Secondary outcome]]s 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 event]]s 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 [[outcome]]s 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 ((Ayling OGS, Alotaibi NM, Wang JZ, Fatehi M, Ibrahim GM, Benavente O, Field TS, Gooderham PA, Macdonald RL. Suboccipital Decompressive Craniectomy for cerebellar infarction: A Systematic Review and Meta-Analysis. World Neurosurg. 2018 Feb;110:450-459.e5. doi: 10.1016/j.wneu.2017.10.144. Epub 2017 Dec 2. PMID: 29104155.)). ===== Outcomes ===== cerebellar infarction and associated brain edema due to [[brainstem compression]] or [[obstructive hydrocephalus]] cause consciousness disturbance. In such cases, the mortality rate is reported to be 84% ((Feely MP. [[cerebellar infarction]]. Neurosurgery. 1979 Jan;4(1):7-11. doi: 10.1227/00006123-197901000-00003. PMID: 450221.)) when decompressive suboccipital craniectomy (DSC) is not performed ---- The best available [[evidence]] for [[Suboccipital Decompressive Craniectomy]] is based on [[retrospective]] [[observational]] studies. SDC for [[cerebellar infarction]] is associated with better [[outcome]]s 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 ((Ayling OGS, Alotaibi NM, Wang JZ, Fatehi M, Ibrahim GM, Benavente O, Field TS, Gooderham PA, Macdonald RL. [[Suboccipital Decompressive Craniectomy for cerebellar infarction]]: A [[Systematic Review]] and [[Meta-Analysis]]. World Neurosurg. 2018 Feb;110:450-459.e5. doi: 10.1016/j.wneu.2017.10.144. Epub 2017 Dec 2. PMID: 29104155.)). ---- A poor prognosis is inevitable in patients whose infarction is combined with other locations than the [[cerebellum]] but in those who already have [[obstructive hydrocephalus]] at the time of surgery ((Suyama Y, Wakabayashi S, Aihara H, Ebiko Y, Kajikawa H, Nakahara I. Evaluation of clinical significance of decompressive suboccipital craniectomy on the prognosis of cerebellar infarction. Fujita Med J. 2019;5(1):21-24. doi: 10.20407/fmj.2018-010. Epub 2018 Dec 6. PMID: 35111496; PMCID: PMC8766232.)). ---- [[Brainstem infarction]] and bilateral [[cerebellar infarction]] were associated with unfavorable outcome ((Lindeskog D, Lilja-Cyron A, Kelsen J, Juhler M. Long-term functional outcome after decompressive suboccipital craniectomy for space-occupying cerebellar infarction. Clin Neurol Neurosurg. 2018 Dec 1;176:47-52. doi: 10.1016/j.clineuro.2018.11.023. [Epub ahead of print] PubMed PMID: 30522035. )). ---- Favorable clinical outcomes including [[overall survival]] can be expected after preventive [[Suboccipital Decompressive Craniectomy]] in patients with a volume ratio between 0.25 and 0.33 and the absence of [[brainstem infarction]]. Among these patients, preventive [[Suboccipital Decompressive Craniectomy]] might be better than the best medical treatment alone ((Kim MJ, Park SK, Song J, Oh SY, Lim YC, Sim SY, Shin YS, Chung J. Preventive [[Suboccipital Decompressive Craniectomy for cerebellar infarction]]: A [[Retrospective]]-Matched Case-Control Study. Stroke. 2016 Oct;47(10):2565-73. doi: 10.1161/STROKEAHA.116.014078. Epub 2016 Sep 8. PMID: 27608818.)). ===== Case series ===== [[Suboccipital Decompressive Craniectomy for cerebellar infarction Case series]]. ===== Case reports ===== [[Suboccipital Decompressive Craniectomy for cerebellar infarction Case reports]].