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Cerebellar Stroke

Definition A cerebellar stroke occurs when the blood supply from one or more of the blood vessels (superior cerebellar artery, anterior inferior cerebellar artery, or posterior inferior cerebellar artery) to the cerebellum is interrupted 1 .

Epidemiology

Strokes are the third leading cause of death in North America 2 . Cerebellar strokes occur in 1.5% to 3.8% 3,4 of all strokes. The mortality rate associated

with cerebellar stroke is 23%

3

.

Pathophysiology of Cerebellar Stroke The cerebellum is the second largest part of the brain. The main functions of the cerebellum include coordination of posture and gait; coordination of voluntary muscle activity and muscle tone; coordination of location in space and movement; and regulation of fine movements especially in the distal muscles of the hand. The cerebellum is supplied by three arteries: the superior cerebellar artery (SCA) and the anterior inferior cerebellar artery (AICA) which arise from the basilar artery, and the posterior inferior cerebellar artery (PICA) arises from the vertebral artery 5 . Hypertension and cardioaortic diseases are the major causes of cerebellar infarction 1 . Cerebellar stroke is mainly related to ischemic events, in which, most cases are resulted from embolism (50%); occlusion or stenosis of the cerebellar artery. Arthrosclerotic branches in the cerebellar artery (28%) is the second most common cause 6 . Other risk factors for cerebellar strokes include hyperlipidemia, a previous transient ischemic attack, diabetes mellitus, and a hypercoagulable state 7 . The posterior fossa is very limited in space. It is unable to accommodate the increased volume if edema occurs after cerebellar stroke. Thirty nine percent of patient with a cerebellar stroke develop mass effect due to edema 8 . The mass effect moves the cerebellar tissue forward and upward, which compresses the 4 th ventricle and/or cerebral aqueduct and obstructs the cerebrospinal fluid (CSF) flow. Disturbance of the CSF flow results in obstructive hydrocephalus 9 . The ischemic process of cerebellar stroke can be extended to the brain stem and cause brain stem infarction and locked-in syndrome 3,10 .

Manifestation

The most common manifestations of cerebellar strokes are a loss in coordination that may affect speech (dysarthria), posture/locomotion (bradykinesia), oculomotor movement (nystagmus),

and upper

limb movement 11 . Patients with a

cerebellar stroke may also present with acute

vestibular syndrome which is the rapid onset of vertigo, nausea/vomiting, and gait unsteadiness in association with head motion intolerance and

nystagmus 12,13 . Rapid deterioration in patients with cerebellar stroke is usually related to the stroke extending to

the brain stem, and from obstruction of the

4 th

ventricle and/or the cerebral aqueduct due to

cerebellar edema 7 .

Diagnostic tests

Cerebellar stroke is difficult to diagnose because its manifestations are ambiguous and the initial computed tomography scan (CT scan) may be negative 10 . The most commonly used diagnostic tests include CT scan and magnetic resonance imaging (MRI). CT scan is useful to assess a hemorrhage, however, its sensitivity to detect ischemic strokes is only approximate 40% and it is extremely insensitive to identify cerebellar strokes 14 . MRI is able to provide information about the infraction, vessel status, and the extent of the lesion. Diffusion-weighted MRI can detect ischemic lesions more precisely and in the initial hours after stroke onset 14 .

and in the initial hours after stroke onset 1 4 . CT scan shows a large

CT scan shows a large cerebellar stroke (Arrow)

A cerebral angiogram may be performed to visualize the status of the cerebral vasculature. It is not commonly performed because it is invasive, but it can be used for removing blood clots for recanalization of the blood vessels 10,15 . Other diagnostic tests may include electrocardiogram, transthoracic echocardiogram, transesophageal echocardiogram, or transcranial doppler to assess the etiology of the diagnosis 7 .

Treatment Options Intravenous thrombolysis has been used to recanalize the occluded cerebellar artery 16 . Intra- arterial thrombolysis has been demonstrated to be

effective in improving patients’ outcome and may even reverse locked-in syndrome 10 . When patients have severe cerebellar edema, urgent surgical decompression of the posterior fossa is required to reduce the increased intracranial pressure and prevent upward herniation or hydrocephalus 3,10 . The use of an external ventricular drain to reduce intracerebral hypertension for patients with cerebellar stroke is controversial because of the risk of upward herniation 7 . However, Kirollos et al. 17 suggest using a ventricular drain and surgical intervention together as an effective way to reduce the mass effect of cerebellar edema.

Nursing Implications Timely recognition of neurological deterioration is

essential to detect extension of the infarction and/or cerebellar edema 10,17 . A cerebellar stroke could cause significant

neurological deficits especially in the SCA territory

Early rehabilitation is important to optimize functional recovery 2,20 . Motor recovery, especially upper limb function, is important to rehabilitate in the first two

weeks after the

acute phase 11 . The functional

21

disability from ataxia is able to be rapidly improved or

overcome with appropriate physiotherapy 4 .

Reference

1) Nelson,

J.A.,

&

Viirre,

E. (2009). The clinical

differentiation of cerebellar infraction from common vertigo syndrome. Western Journal of Emergency Medicine, 10, 273-277.

2) Hickey, J.V. (2003). The clinical practice of neurological

ed.). Philadelphia:

Lippincott Williams & Wilkins. 3) Macdonell, R.A.L., Kalnins, R.M., & Donnan, G.A. (1987). Cerebellar infarction: natural history, prognosis, and pathology. Stroke, 18, 849-855.

4) Ng, Y.S., Stein, J., Ning, M.M., & Black-Schaffer, MR.M. (2007). Comparison of clinical characteristics and functional outcomes of ischemic stroke in different vascular territories. Stroke, 38, 2309-2314. 5) Chaves, C.J., Caplan, L.R., Chung, S.C., Tapia, J., Amarenco, P., Teal, P., Wityk, R., Estol, C., Tettenborn, B., Rosengart, A., Vemmos, K., DeWitt, L.D., & Pessin, M.S. (1994). Cerebellar infarcts in the New England Medical center posterior circulation stroke registry. Neurology, 44, 1385-1390. 6) Amarenco, P., Levy, C., Cohen, A., Touboul, P.J. Etienne Roullet, E., & Bousser, M.G. (1994). Causes and Mechanisms of Territorial and Nonterritorial Cerebellar Infarcts in 115 Consecutive Patients. Stroke, 25, 105-112.

7) Erdemoglu,

Superior

cetebellar artery territory stroke. Acta Neurologica Scandinavica, 98, 283-287. 8) Koh, M.G., Phan, T.G., Atkinson, J.L.D., & Wijdicks, E.F.M. (2000). Neuroimaging in deteriorating patients

and neurosurgical nursing. (5

th

A.K.

&

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(1998).

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10)

Predicting neurologic deterioration in patients with cerebellar hematoma. Neurology, 51, 1364-1369. Wijdicks, E.F.M. (2004). Cerebellar stroke: More than

meets the eye. Reviews in Neurological Diseases, 1,

211-213.

11) Konczak, J., Pierscianek, D., Hirsiger, S., Bultmann, U., Schoch, B., Gizewski, E.R., Timmann, D., Maschke, M., & Frings, M. (2010). Recovery of upper limb function after cerebellar stroke: Lesion symptom mapping and arm kinematics. Stroke, 41, 2191-2200.

Choi, K.D., Lee, H., & Kim, J.S. (2013). Vertigo in

brainstem and cerebellar strokes. Current Opinion in Neurology, 26, 90-95. 13) Newman-Toker, D.E., Kattah, J.C., Alvernia, J.E., & Wang, D.Z. (2008). Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology, 70, 2378-2385.

Morita, S., Suzuki, M., & Iizuka, K. (2011). False-

negative diffusion-weighted MRI in acute cerebellar

. stroke. Auris Nasus Larynx, 38, 577-582. 15) Reich, P., Müller-Schunk, S., Liebetrau, M., Scheuerer, W., Brückmann, H., & Hamamm, G.F. (2003). Combined cerebellar and bilateral cervical posterior spinal artery stroke demonstrated on MRI. Cerebrovascular Diseases, 15, 143-147. 16) Gobert, F., Cho, T.H., Desilles, J.P., Hermier, M., Mechtouff, L., Derex, L., & Nighoghossian, N. (2011). Magnetic resonance imaging–based intravenous thrombolysis 6 hours after onset of minor cerebellar stroke. Archives of Neurology, 68, 678. 17) Kirollos, R.W., Tyagi, A.K., Ross, S.A., van Hille, P.T., & Marks, P.V. (2001). Management of spontaneous cerebellar hematomas: a prospective treatment protocol. Neurosurgery, 49, 1378-1387.

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Casini, L., & Ivry, R.B. (1999). Effects of divided

attention on temporal processing in patients with lesions of the cerebellar or frontal lobe. Neuropsychology, 113(1), 10-21. 20) Kelly, P.J., Stein, J., Shafqat, S., Eskey, C., Doherty, D., Chang, Y., Kurina, A., & Furie, K.L. (2001). Functional recovery after rehabilitation for cerebellar stroke. Stroke, 32, 530-534.

©2013

Disclaimer: The author of this article neither represents nor guarantees that the practices described herein, if followed, ensure safe and effective patient care. The author further assumes no responsibility or liability in connection with any information or recommendations contained in this article. The recommendations and instructions in this article are based on the knowledge and practice in neuroscience as of the date of publication. These recommendation and instructions are subject to change based on the availability of new scientific information.