Functional Outcomes in Conservatively vs Surgically Treated Cerebellar Infarcts

So your doctors still have NO protocol to follow when you arrive with a stroke.

We may as well go back to blood letting as a stroke prescription as discussed in the 1843 book, 'An Essay On The Nature and Treatment of Apoplexy'.

Hope your doctors have learned a few things since then. But obviously not enough to demand a protocol be created for treating stroke patients. Don't give me the crapola about; 'All strokes are different, all stroke recoveries are different'. That's just lazy thinking, leaders would find the commonalities and work toward 100% recovery

Functional Outcomes in Conservatively vs Surgically Treated Cerebellar Infarcts

Sae-Yeon Won, MD¹; Silvia Hernández-Durán, MD²; Bedjan Behmanesh, MD¹; et al Joshua D. Bernstock, MD, PhD, MPH³; Marcus Czabanka, MD⁴; Nazife Dinc, MD⁵; Daniel Dubinski, MD, MSc¹; Thomas M. Freiman, MD¹; Albrecht Günther, MD⁶; Kara Hellmuth, BSc¹; Eva Herrmann, PhD⁷; Juergen Konczalla, MD⁴; Ilko Maier, MD⁸; Ruzanna Melkonian, MD⁵; Dorothee Mielke, MD²; Paul Naser, MD⁹; Veit Rohde, MD²; Christian Senft, MD⁵; Alexander Storch, MD¹⁰; Andreas Unterberg, MD⁹; Johannes Walter, MD⁹; Uwe Walter, MD¹⁰; Matthias Wittstock, MD¹⁰; Jan Hendrik Schaefer, MD¹¹; Florian Gessler, MD, PhD¹

Author Affiliations

JAMA Neurol. Published online February 26, 2024. doi:10.1001/jamaneurol.2023.5773

Key Points

Question  What is the functional outcome in surgically compared with medically managed patients with cerebellar infarcts?

Findings  In this cohort study including 531 participants, there was no difference in favorable outcome at discharge and follow-up between surgically and medically managed patients with cerebellar infarcts. When stratified by volume, larger cerebellar infarcts were associated with a favorable outcome at follow-up if managed surgically, while conservative management yielded more favorable outcomes when infarcts were smaller.

Meaning  Surgical treatment may be beneficial in patients with large cerebellar infarcts, whereas conservative treatment may be reasonable in patients with lower infarct volumes.(Well define a cutoff line; that's what leaders do, they solve problems!)

Abstract

Importance  According 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.

Objective  To evaluate functional outcomes in surgically compared with conservatively managed patients with cerebellar infarcts.

Design, Setting, and Participants  In 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.

Exposures  Surgical treatment (ie, posterior fossa decompression plus standard of care) vs conservative management (ie, medical standard of care).

Main Outcomes and Measures  The 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.

Results  Of 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 > .99) or at follow-up (35 [73%] vs 33 [61%]; odds ratio, 1.8; 95% CI, 0.7-4.2; P > .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 Relevance  Overall, 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.