Cerebellar stroke
Cerebellar stroke, ischemic or hemorrhagic infarction of the cerebellum, presents with vertigo, truncal ataxia, dysarthria, and limb incoordination and is diagnosed with brain MRI when CT is falsely reassuring. Its defining danger is delayed swelling that compresses the brainstem and fourth ventricle, which is treated with emergent decompressive suboccipital craniectomy.
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What this article covers
- Overview
Definition: cerebellar stroke is ischemic infarction or hemorrhage confined to the cerebellum, most often from occlusion of the posterior inferior cerebellar artery (PICA), superior cerebellar artery…
- Epidemiology
Cerebellar strokes account for a minority of all strokes: roughly 2-3% of ischemic strokes, likely an undercount given misdiagnosis as peripheral vertigo.
- Risk factors
Hypertension: the leading risk factor for both infarction and, especially, hemorrhage.
- Pathophysiology
Ischemic mechanism: occlusion of PICA, SCA, or AICA from atherosclerosis, embolism, or dissection interrupts flow to the corresponding territory, sometimes extending into the adjacent lateral medulla or pons.
- Clinical features
Vertigo and imbalance are the dominant early symptoms: acute, persistent dizziness with nausea and vomiting is the most common presenting complaint and is frequently mistaken for a peripheral vestibular disorder.
- Differential diagnosis
Peripheral vestibulopathy (vestibular neuritis, labyrinthitis, benign paroxysmal positional vertigo): unidirectional, horizontal-torsional nystagmus that suppresses with visual fixation, and a…
- Diagnosis
Diagnosis is established by a compatible acute vestibulocerebellar syndrome plus imaging evidence of infarction or hemorrhage in a cerebellar vascular territory.
- Management
First, assess airway, breathing, and level of consciousness, and treat as an unstable emergency if there is any decline: a patient with a depressed level of consciousness, new brainstem signs, or…
- Complications
Malignant cerebellar edema with brainstem compression: the defining complication, occurring days after infarction or with an expanding hematoma.
- Prognosis
Outcome depends heavily on early recognition of mass effect: patients who undergo timely decompressive surgery have survival and functional outcomes comparable to those without herniation, while delayed recognition carries high mortality.
- Prevention
Blood pressure control is the single most important measure, with a target below 130/80 mmHg once the acute period has passed.
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Related articles
- Ischemic stroke
Ischemic stroke is sudden focal neurologic deficit from arterial occlusion confirmed by infarction on neuroimaging. Diagnosis relies on urgent noncontrast head CT to exclude hemorrhage; treatment is IV alteplase within 4.5 hours and mechanical thrombectomy for large-vessel occlusion within an extended window, followed by antiplatelet therapy and risk-factor control.
- Basilar artery occlusion
Basilar artery occlusion is a posterior circulation large-vessel stroke that threatens the brainstem, cerebellum, and thalami, presenting with rapidly progressive quadriparesis, cranial nerve palsies, and impaired consciousness, up to locked-in syndrome or coma. Diagnosis requires urgent CT angiography, and management is emergent reperfusion with IV alteplase followed by mechanical thrombectomy in eligible patients.
- Vertebral artery dissection
A tear in the vertebral artery wall, spontaneous or from neck trauma or manipulation, that causes posterior circulation ischemia through thrombus formation or direct luminal narrowing. Presents with posterior neck or occipital headache plus brainstem or cerebellar signs, most classically a lateral medullary (Wallenberg) syndrome; diagnosed with MRI/MRA or CT angiography of the neck and treated with antithrombotic therapy.
- Increased intracranial pressure
Sustained intracranial pressure above 20-22 mmHg from mass effect, edema, hydrocephalus, or venous outflow obstruction, diagnosed by clinical signs plus invasive monitoring and treated stepwise with head elevation, hyperosmolar therapy (mannitol or hypertonic saline), CSF diversion, and decompressive surgery when refractory.
- Vertigo
The false sensation of self or environmental movement, classified as peripheral (inner ear or vestibular nerve) or central (brainstem or cerebellum) based on history, nystagmus pattern, and the bedside HINTS exam. Peripheral vertigo is managed with repositioning maneuvers or vestibular suppressants; central vertigo requires urgent stroke evaluation, since it can be the sole presenting symptom of a posterior circulation stroke.