Literature ReviewSuboccipital Decompressive Craniectomy for Cerebellar Infarction: A Systematic Review and Meta-Analysis
Introduction
Cerebellar ischemic infarcts cause space-occupying edema that is most often managed medically. Despite advances in medical therapy for stroke, it has been estimated that 20% of patients with massive cerebellar infarction1, 2, 3, 4 deteriorate clinically as a result of mass effect of the infarct volume. This process may result in morbidity and mortality as a result of either brainstem compression or obstruction of the fourth ventricle, causing acute hydrocephalus and tonsillar herniation.2, 3, 5 Suboccipital decompressive craniectomy (SDC) is the preferred treatment for clinical deterioration caused by space-occupying edema after massive cerebellar infarction.1, 6
Since the first reports of surgical treatment for massive cerebellar infarcts in 1956,7, 8 there have been many reports of SDC. Generally, these reports have indicated that SDC for cerebellar infarction is a life-saving procedure5 and current guidelines from the American Heart Association/Stroke Council's Scientific Statement Oversight Committee recommend that SDC with dural expansion be performed in patients who deteriorate secondary to edema after cerebellar infarction (level 1, class B evidence).1, 6 Despite these recommendations, the estimated overall rates of outcomes and mortality are not well defined after SDC. Existing literature in the field is predominately from retrospective observational studies and case reports,5 which makes it challenging to draw conclusions about the effectiveness of SDC for cerebellar infarction or its associated adverse event rates.
The paucity of high-quality data for SDC after cerebellar stroke, compared with the literature for decompressive craniectomy after malignant middle cerebral artery infarction,9 highlights the need for an analysis of the existing literature to draw more meaningful conclusions regarding SDC outcomes for cerebellar infarction. Therefore, we performed a systematic review and meta-analysis of the existing literature of SDC for the treatment of cerebellar infarction. The aim of the review was to investigate the impact of SDC on functional outcomes, mortality, and adverse events in patients after cerebellar infarction.
Section snippets
Protocol
The search protocol, including the research question and inclusion/exclusion criteria, was developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.10
Search Strategy
We searched the existing literature using keywords to identify cases of SDC for cerebellar infarction. Articles were identified by searching OVID MEDLINE, EMBASE, Web of Science, and Cochrane Library databases from their commencement until November 2016. The reference lists of included
Search Results
The number of articles retained at each stage of data acquisition is shown in a PRISMA flowchart (Figure 1). The full text was reviewed for 58 articles and further screening led to the exclusion of 47 articles, leaving 11 articles for inclusion in the final analysis. Reasons for exclusion are included in Supplementary Table 2.
Study Characteristics
Tables 1 and 2 present the study characteristics of articles included for analysis. The 11 articles3, 15, 16, 20, 21, 22, 23, 24, 25, 26, 27 included for analysis were
Discussion
In this systematic review and meta-analysis of SDC for cerebellar infarct, we show that SDC is associated with an unfavorable outcome in 28.0%, a mortality of 19.9%, for a combined outcome for unfavorable outcome and death of 48%. Furthermore, we show that SDC is associated with an adverse event rate of 22.9%. Although not statistically robust because of the heterogeneous nature of the data, several factors associated with lower rates of unfavorable outcomes and mortality included age <60
References (37)
- et al.
Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials
Lancet Neurol
(2007) - et al.
Assessment of coma and impaired consciousness
Lancet
(1974) - et al.
Meta-analysis in clinical trials
Control Clin Trials
(1986) - et al.
Controversy of surgical treatment for severe cerebellar infarction
J Stroke Cerebrovasc Dis
(2007) - et al.
Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial
Lancet Neurol
(2009) - et al.
What can be learned from the DECRA study
World Neurosurg
(2013) - et al.
Cerebellar strokes: mortality, surgical indications, and results of ventricular drainage
Lancet Lond Engl
(1982) - et al.
Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association
Stroke
(2014) - et al.
Cerebellar infarction. Clinical and anatomic observations in 66 cases
Stroke
(1993) - et al.
Neuroimaging in deteriorating patients with cerebellar infarcts and mass effect
Stroke
(2000)
Cerebellar infarction: natural history, prognosis, and pathology
Stroke
Space-occupying cerebellar infarction: complications, treatment, and outcome
Neurosurg Focus
Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association
Stroke
Cerebellar softening
BMJ
Infarctions simulating brain tumours in the posterior fossa
J Neurosurg
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement
PLoS Med
Recovery of motor function after stroke
Stroke
Disability after severe head injury: observations on the use of the Glasgow Outcome Scale
J Neurol Neurosurg Psychiatry
Cited by (30)
The impact of emergent suboccipital craniectomy upon outcome & prognosis of massive cerebellar infarction: A single institutional study
2021, Interdisciplinary Neurosurgery: Advanced Techniques and Case ManagementCitation Excerpt :This malignant cerebellar infarction is a life-threatening incident, considered to be an emergency as any post fossa hemorrhage or space-occupying lesion and has been estimated to record a 20% incidence of occurrence and it is featured by the presence of ongoing depression of conscious level as a result of associated significant edema, compression/or distortion of the brainstem, brain herniation whether downward or upward and obstructive hydrocephalus. A graver presentation is that of bilateral cerebellar affection caused by posterior inferior cerebellar artery (PICA) acute occlusion which is typically associated with infarction of the brainstem [4,21]. It has been recognized that whenever decompressive suboccipital craniectomy (DSC) is not achieved, an 84% mortality rate follows for those cases with acute cerebellar infarction associated with extensive swelling compromising the normal CSF outflow, and/or brainstem distortion and resulting in deterioration of consciousness [7].
Decompressive Craniectomy for Infarction and Intracranial Hemorrhages
2021, Stroke: Pathophysiology, Diagnosis, and ManagementCerebellar Necrosectomy Instead of Suboccipital Decompression: A Suitable Alternative for Patients with Space-Occupying Cerebellar Infarction
2020, World NeurosurgeryCitation Excerpt :However, other investigators, such as Chen et al.13 and Raco et al.,20 have advised the exhaustion of conservative and minimally invasive alternatives before performing surgery. Although some studies have reported an increase in unfavorable outcomes after supra- and infratentorial infarction in the elderly, this factor has not been conclusively clarified.6,28 In particular, data from patients with infratentorial infarction have provided different results and are only comparable to a limited extent owing to differences in the treatment regimens.6
Predicting Surgical Intervention in Cerebellar Stroke: A Quantitative Retrospective Analysis
2020, World Neurosurgery
Supplementary digital content available online.
Conflict of interest statement: Dr. Macdonald receives grant support from the Physicians Services Incorporated Foundation, Brain Aneurysm Foundation, Canadian Institutes for Health Research, and the Heart and Stroke Foundation of Canada; and is Chief Scientific Officer of Edge Therapeutics, Inc. The other authors declare that they have no competing interests.