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Cerebellar Infarction

A cerebellar infarction is an acute medical condition or a stroke induced by a prolonged and complete occlusion of one of the arteries that are responsible for the perfusion of the cerebellum.


Presentation

The symptoms of a cerebellar infarct clearly depict the region of the cerebellum that is subjected to ischemic damage. In addition to specific symptoms, there are other non-specific symptoms like headaches, dizziness, and vomiting.

A blockage of blood flow in the superior, anterior inferior or posterior inferior cerebellar arteries can result in a cerebellar infarction. The primary region affected is the brainstem, and, therefore, the symptoms clearly depict various degrees of damage to this anatomical structure. Symptoms typical of a cerebellar infarct include dysarthria, diplopia, muscle weakness, limb ataxia and isolated vertigo, usually constituting an occlusion of the posterior inferior cerebellar artery [1].

The symptomatology related to a cerebellar infarction tends to arise spontaneously and then progresses rapidly, while risk factors such as hypertension and cardiovascular disease usually complete the patient's background [2]. Profound ataxia, vertigo, and multidirectional nystagmus are three symptoms that raise considerable suspicion of a cerebellar infarction and should be investigated in depth since their misinterpretation lays the foundation for many cases of undiagnosed cerebellar infarctions [3].

Additionally, multidirectional nystagmus also referred to as gaze-evoked or direction-changing nystagmus, encompasses a change in the direction of nystagmus, depending on the direction of the patient's gaze. This symptom evinces a more than 50% sensitivity for the diagnosis of a cerebellar infarction [4]. In order to elicit an irrefutable gaze-evoked nystagmus sign, extreme lateral strain should be avoided [5]

Falling
  • […] and falling with OT and skew deviation if nodulus is infarcted.[ncbi.nlm.nih.gov]
  • The most common clinical finding was severe gait ataxia with sudden falling (n 9) or severe veering (n 2). Cerebellar dysarthria was found in 8 patients. Eight patients had a mild unilateral limb ataxia.[ncbi.nlm.nih.gov]
  • Downbeat nystagmus and a right falling tendency were observed. Brain MRI showed multiple acute infarctions in the left cerebellum.[ncbi.nlm.nih.gov]
  • Cerebellar infarction related OH was defined as fall in BP ( 20 mmHg systolic BP) on tilting in patients without any disease(s) that could potentially cause autonomic dysfunction, or in patients who had a potential cause of autonomic dysfunction, but[ncbi.nlm.nih.gov]
  • Gait imbalance usually sudden and severe; patients tend to fall toward the side of the cerebellar lesion (ipsilateral axial lateropulsion) Limb ataxia occurs in half (50%) Severe cerebellar mass effect in 30%, resulting in hydrocephalus in 20%, resulting[wikidoc.org]
HELLP Syndrome
  • HELLP syndrome may have contributed to the development of cerebellar infarction in the case. Copyright 2002 S. Karger AG, Basel[ncbi.nlm.nih.gov]
  • After 2 h, the patient underwent caesarean section for diagnosis of haemolysis, elevated liver enzymes, low platelet (HELLP) syndrome.[ncbi.nlm.nih.gov]
Walking with a Cane
  • Vertigo gradually improved, and the patient was able to walk with a cane. Previously slurred speech was completely resolved. This case demonstrates that a Jefferson fracture can cause vertebral artery occlusion, resulting in cerebellar infarction.[ncbi.nlm.nih.gov]
Joint Subluxation
  • Atlantoaxial joint subluxation and vertical subluxation of the axis may occur as a consequence of instability resulting from the inflammatory process.[ncbi.nlm.nih.gov]
Vertigo
  • The patient's vertigo and hemiplegia improved completely after treatment. Case 2, a 50-year-old man who experienced sudden vertigo and sensorineural hearing loss (SNHL), developed dysarthria after admission.[ncbi.nlm.nih.gov]
  • The most common symptoms in patients with isolated cerebellar infarctions were vertigo (87%) and lateropulsion (82%). Isolated vertigo or lateropulsion without any other symptoms was present in 38% of patients.[ncbi.nlm.nih.gov]
  • Two types of cerebellar infarction simulating VN were found: isolated spontaneous prolonged vertigo with imbalance as a sole manifestation of cerebellar infarction (n 24) and isolated spontaneous prolonged vertigo with imbalance as an initial manifestation[ncbi.nlm.nih.gov]
  • A 40-yr-old man developed severe vertigo, nausea, and vomiting during initial aircraft descent. Head computed tomography scan was performed acutely and was normal. Initial assessment was benign paroxysmal positional vertigo.[ncbi.nlm.nih.gov]
  • In this report, we present a young patient manifesting with repeated vertigo. Owing to the initial misdiagnosis, the patient later developed cerebellar stroke with inability to stand or walk.[ncbi.nlm.nih.gov]
Dizziness
  • He then experienced continuous vomiting and dizziness. Magnetic resonance imaging revealed acute infarction in the right cerebellar hemisphere, and magnetic resonance angiography revealed transient stenosis of the right superior cerebellar artery.[ncbi.nlm.nih.gov]
  • In this report, we present a 55-year-old male who admitted to hospital with vomiting, nausea and dizziness. On examination left-sided hemiparesia and ataxic gait were detected.[ncbi.nlm.nih.gov]
  • We herein report a 51-year-old man developed sudden dizziness, nausea and vomiting. CT revealed hypodense bilateral lesions over the cerebellum corresponding to the medial PICA (mPICA) branch territory.[ncbi.nlm.nih.gov]
  • Four months after his vestibular injury, his symptoms of dizziness had not resolved. He had a spontaneous vestibular nystagmus, and laboratory testing indicated an asymmetric semicircular canal-ocular reflex.[ncbi.nlm.nih.gov]
  • Abstract Cerebellar infarction presents with symptoms of nausea, vomiting, and dizziness and thus mimics benign conditions such as viral gastroenteritis or labyrinthitis, which constitutes a good proportion of patients seen in the emergency department[ncbi.nlm.nih.gov]
Nystagmus
  • To define the characteristics and mechanism of head-shaking nystagmus in central vestibulopathies, we investigated spontaneous nystagmus and head-shaking nystagmus in 72 patients with isolated cerebellar infarction.[ncbi.nlm.nih.gov]
  • In most (82%, 9/11) patients with SN or GEN, the nystagmus subsided within 1 week after hospitalisation. DISCUSSION: Vertigo and nystagmus in SCA territory cerebellar infarction are more common than previously thought.[ncbi.nlm.nih.gov]
  • Additionally, multidirectional nystagmus also referred to as gaze-evoked or direction-changing nystagmus, encompasses a change in the direction of nystagmus, depending on the direction of the patient's gaze.[symptoma.com]
  • KEYWORDS: Cerebellar infarction; Cerebellum; Ocular fixation; Spontaneous nystagmus[ncbi.nlm.nih.gov]
  • Nystagmus was associated with lesions in the pyramis lobule, while lesions of the anterior paravermis were associated with dysarthria and limb ataxia.[ncbi.nlm.nih.gov]
Tremor
  • Abstract We report a 67-year-old man who developed yes/yes head tremor without appendicular tremor six weeks after right occipital and bilateral cerebellar infarction. The tremor was resting-postural.[ncbi.nlm.nih.gov]
  • Abstract We describe a case of bilateral olivary hypertrophy and palatal tremor after unilateral cerebellar infarction.[ncbi.nlm.nih.gov]
  • Tremor Cerebellar lesions can produce unilateral or bilateral intention tremor, or a truncal tremor. Nausea and vomiting Cerebellar lesions can produce nausea and/or vomiting.[patient.info]
  • Double vision, speech problems, tremors, and jerking movement may result from a cerebellar stroke.[verywell.com]
  • Tremor: in volitional muscle contraction. – Positional postural action static (hands stretched out “stop” sign in volitional muscle contraction).[slideshare.net]
Cerebellar Ataxia
  • On neurological examination he had right cerebellar ataxia. Computed tomography and magnetic resonance imaging, revealed an acute right cerebellar infarction in the anterior inferior cerebellar artery territory.[ncbi.nlm.nih.gov]
  • Idiopathic cerebellar ataxia - a diagnosis of exclusion. Presentation As the cerebellum is associated with motor control, lesions produce a range of movement disorders (ataxias). These can be differentiated by their time course.[patient.info]
  • ataxia ) Basal ganglia Chorea Dystonia Parkinson's disease Cortex ACA syndrome MCA syndrome PCA syndrome frontal lobe : Expressive aphasia Aboulia parietal lobe : Receptive aphasia Hemispatial neglect Gerstmann syndrome Astereognosis occipital lobe :[en.wikipedia.org]
  • Cerebellar ataxia and gait disturbance were evident. Diffusion weighted imaging (DWI) demonstrated multiple cerebellar infarctions at several intensities with perilesional edema of the left cerebellar hemisphere (Fig. 1a, b ).[bmcneurol.biomedcentral.com]

Workup

The workup involved in the investigation of a potential cerebellar infarction encompasses three vital steps: a thorough clinical examination, imaging modalities to confirm clinical suspicion and glucose testing, as well as, investigations to determine the possible cause, should it be unknown.

Initially, a cerebellar infarction caused by a thrombotic event is suspected when an acute neurologic impairment is observed corresponding to the arterial occlusion of a specific cerebellar artery. Non-specific symptoms, such as headaches, vomiting and coma/stupor are more indicative of a hemorrhagic event. A clinical diagnosis of the exact arterial branch that has been occlusion is often impossible, with the symptoms and progression being only indicative of the particular characteristics of each event.

Neuroimaging is an essential method to diagnose the infarction. A computerized tomography scan (CT scan) can detect the region of the arterial occlusion, but its sensitivity increases with the progression of the event [6]. It also constitutes a means to differentiate between a cerebellar infarction, a tumor, hemorrhage, subdural or epidural hematoma and is indicated in patients who require special equipment for monitoring and life support [7]. A magnetic resonance imaging scan (MRI) is able to detect an infarction earlier during the course and with greater sensitivity than a CT scan; small infarctions may even be detected solely by means of a magnetic resonance imaging scan (MRI scan). Diffusion-weighted imaging (DWI) is an extremely useful tool for the evaluation of patients with a transient ischemic attack [8].

In order to diagnose the etiology of the infarction, vascular, cardiac and hematological evaluation are carried out:

Possible cardiac pathology can be detected with an electrocardiogram, telemetry, serum troponin, Holter monitoring and an echocardiogram.

Investigations including a magnetic resonance angiography (MRA), a computerized tomography angiography, conventional angiography, carotid and transcranial duplex ultrasonography, can be performed in order to assess an underlying vascular pathology.

Disorders that affect the coagulation cascade can lead to a hypercoagulative disorder, that may lead to a thrombotic cerebellar infarction. Laboratory evaluation of the platelet count, a complete blood count and a PT/PTT measurement can provide the initial clues of a coagulation pathology. An accurate diagnosis will be established as soon as additional tests are performed, such as homocysteine, antithrombin III, factor V Leiden levels, as well as various other indicators.

Treatment

  • Timely escalation of treatment is crucial and should be guided by clinical and neuroradiological rationales.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: In the absence of brain stem infarcts, surgical treatment resulted in a favorable clinical outcome and should be considered a treatment option for patients with expansive bilateral cerebellar infarction. 2010 John Wiley & Sons A/S.[ncbi.nlm.nih.gov]
  • Baseline data included clinical findings, Glasgow Coma Scale on admission and before surgery, NIHSS on admission, mass effects on neuroimaging, and surgical treatment strategies.[ncbi.nlm.nih.gov]
  • Abstract Treatment for severe cerebellar infarction has been controversial. Clinical outcomes of patients with external ventricular drainage (EVD) and decompression as the first treatment for the infarction were compared.[ncbi.nlm.nih.gov]
  • Edaravone, a free radical scavenger, may be useful in the treatment of vertigo and SNHL. Copyright 2013 Elsevier Ireland Ltd. All rights reserved. KEYWORDS: Edaravone; Free radical; Hearing loss; Vertigo[ncbi.nlm.nih.gov]

Prognosis

  • Unlike massive hemispherical infarctions, in pure cerebellar infarctions, the prognosis is better. This case report discusses, a 61 year old lady who presented with atrial fibrillation and a massive cerebellar infarction.[ncbi.nlm.nih.gov]
  • Though the prognosis is usually considered good, our patient made poor recovery.[ncbi.nlm.nih.gov]
  • Earlier recognition of this fungal infection improves the prognosis.[ncbi.nlm.nih.gov]
  • Patients in group B had a significantly better prognosis than those in group A. No clear evidence of surgical indications for EVD or suboccipital decompression from neurologic signs or symptoms and from neuroimaging has been reported.[ncbi.nlm.nih.gov]
  • Prognosis correlates to a large extent with the size of infarct.[wikidoc.org]

Etiology

  • In addition, the etiology of retroclival epidural hematomas were also discussed.[ncbi.nlm.nih.gov]
  • We report a case of cerebellar infarction after repeated sports-related minor head injuries in a young adult and discuss the etiology.[ncbi.nlm.nih.gov]
  • Awareness of the possibility of central etiologies and careful clinical evaluation with application of bedside screening methods in patients with acute vestibular symptoms will reduce the number of inaccurate diagnoses.Hesselbrock RR.[ncbi.nlm.nih.gov]
  • In order to diagnose the etiology of the infarction, vascular, cardiac and hematological evaluation are carried out: Possible cardiac pathology can be detected with an electrocardiogram, telemetry, serum troponin, Holter monitoring and an echocardiogram[symptoma.com]
  • . • Acute vestibular syndrome can be due to stroke, and bedside neurologic testing has been shown to be highly sensitive for detection of a central etiology, even in the setting of a negative brain MRI. • Patients with large cerebellar ischemic strokes[medlink.com]

Epidemiology

  • METHODS: The writing group used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion[ncbi.nlm.nih.gov]
  • Anatomical Distribution Superior cerebellar artery territory (SCA) – middle region Anterior inferior cerebellar artery territory (AICA) – middle region Posterior inferior cerebellar artery (PICA) – proximal region Epidemiology and Demographics Infarcts[wikidoc.org]
  • We recorded the following epidemiological variables from each patient: sex, age, presence of cardiovascular risk factors (smoking, high blood pressure, diabetes mellitus, dyslipidaemia, presence of cardioembolism) and aetiology (TOAST criteria 18 ).[elsevier.es]
  • Please refer to the article on cerebral sinus thrombosis for a general discussion on epidemiology and risk factors. Other causes of venous occlusion should also be considered ( dural AVF , trauma, ligation).[radiopaedia.org]
  • Google Scholar 19 Statistical and Epidemiology Research Corporation. Manual for Epidemiological Graphics, Estimation, and Testing Package . Seattle, Wash: Statistical and Epidemiological Research Corp; 1991.[stroke.ahajournals.org]
Sex distribution
Age distribution

Pathophysiology

  • However, massive cerebral infarction leading to death is rare and its pathophysiology is unclear. We report a case of CM causing massive cerebellar infarction, which led to cerebral herniation and death.[ncbi.nlm.nih.gov]
  • Gain fresh perspectives and up-to-date insights from the world’s leading authorities on the pathophysiology, diagnosis, and management of stroke.[books.google.com]
  • SUMMARY: We first briefly review the clinical presentation of cerebellar infarctions, followed by a short refresher on cerebellar anatomy and pathophysiological mechanisms of cerebellar infarcts.[ncbi.nlm.nih.gov]
  • ., M.D. [1] Overview Pathophysiology Mechanism Strokes are usually due to atherosclerotic disease or embolic events. Less common causes are trauma, tumor, arterial dissection, migraine, fibromuscular dysplasia or vasculitis.[wikidoc.org]
  • Summary: We first briefly review the clinical presentation of cerebellar infarctions, followed by a short refresher on cerebellar anatomy and pathophysiological mechanisms of cerebellar infarcts.[karger.com]

Prevention

  • Group A (n 28) consists of those who underwent preventive SDC, and group B (n 56) consists of those who did not undergo preventive SDC. We analyzed and compared clinical outcomes between groups.[ncbi.nlm.nih.gov]
  • Stent-assisted angioplasty of the right VA was performed to prevent recurrence of the cerebellar infarction. Post-procedure, the neuropsychology tests showed cognitive improvement to MMSE score of 26 and WAIS-R score of 84.[ncbi.nlm.nih.gov]
  • To prevent rebleeding, maximal hemostasis was ensured during the neurosurgical intervention.[ncbi.nlm.nih.gov]
  • However, early correct diagnosis is crucial to help prevent treatable but potentially fatal complications, such as brainstem compression and obstructive hydrocephalus.[ncbi.nlm.nih.gov]

References

Article

  1. Afifi AK, Bergman RA. Functional Neuroanatomy Text and Atlas. McGraw-Hill Companies 1998.
  2. Tohgi H, Takahashi S, Chiba K, et al. Cerebellar infarction. Clinical and neuroimaging analysis in 293 patients. The Tohoku Cerebellar Infarction Study Group. Stroke. 1993;24:1697–701.
  3. Hotson JR, Baloh RW. Acute vestibular syndrome. N Engl J Med. 1998;339:680–5.
  4. Lee H, Sohn SI, Cho YW, et al. Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns. Neurology. 2006;67:1178–83.
  5. Leigh RJ, Rucker JC. Nystagmus and related ocular motility disorders. In: Miller NR, Newman NJ, editors. Walsh and Hoyt’s Clinical Neuro-Opthalmology. Baltimore, MD: Lippincott, Williams & Wilkins; 2004.
  6. Shinichi N, Tsutomu I, Hirokazu K, Takumi Y, Tokuro I, Shinichiro W. Correlation of Early CT Signs in the Deep Middle Cerebral Artery Territories with Angiographically Confirmed Site of Arterial Occlusion. AJNR Am J Neuroradiol. 2001 Apr;22(4):654-9.
  7. Byrne JV. The aneurysm "clip or coil" debate. Acta Neurochir (Wien). 2006 Feb. 148(2):115-20.
  8. Sorensen AG, Buonanno FS, Gonzalez RG, et al. Hyperacute stroke: evaluation with combined multisection diffusion-weighted and hemodynamically weighted echo-planar MR imaging. Radiology. 1996 May; 199(2):391-401.

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Last updated: 2018-06-22 01:51