What is Cerebellar Infarct (Cerebellar Stroke)?
A cerebellar infarct, or cerebellar stroke, happens when there’s a disruption in blood flow to the back part of the brain, particularly the cerebellum. This reduced blood flow affects the delivery of oxygen, which could interfere with motor skills and balance. If it’s a hemorrhagic stroke, which is caused by bleeding, it can cause additional damage and make these problems worse. Although cerebellar strokes only make up a small percentage of all strokes, they are significant contributors to disease and death. This is because their initial symptoms are often not obvious, and the swelling that happens in response can cause other problems in the back part of the brain. Cerebellar strokes represent 1% to 4% of all strokes in the brain.
What Causes Cerebellar Infarct (Cerebellar Stroke)?
Strokes that occur in the cerebellum, the part of the brain that controls balance and coordination, can be split into two types: ischemic and hemorrhagic. Ischemic strokes happen when the arteries that supply the cerebellum are blocked, stopping the flow of blood and oxygen. The blockage can come from things like clots that formed in the heart and were carried by the bloodstream, or they can form directly in the blood vessels near or in the cerebellum. They can affect both large and small blood vessels, and can often be caused by conditions such as hardening of the arteries or diseases affecting blood vessels, like arterial dissection.
Sometimes clots that cause these strokes come from the heart, particularly when the heart isn’t pumping properly or beats irregularly, disrupting normal blood flow in the heart. This is common in conditions like atrial fibrillation or atrial flutter. Clots can also come from the veins if there’s an abnormal connection that allows blood to travel from the right side of the heart to the left, as can happen in a condition called patent foramen ovale. In cases of cerebral venous thrombosis, a blockage on the vein’s outflow pathway can result in stroke or bleeding in the brain.
Hemorrhagic strokes, on the other hand, typically occur when blood leaks from arteries and causes damage to the brain tissue, or obstructs the blood flow due to the pressure from the accumulated blood. This type of stroke often happens suddenly, particularly in individuals with a history of high blood pressure or those who are taking blood-thinning medication or drugs that reduce blood clotting. Sometimes, ischemic strokes can turn into hemorrhagic strokes, and this can also happen if the brain tissue gets damaged by a tumor or trauma. Additionally, subdural hematomas, which are usually caused by tears in the small veins situated between the outer and middle layers of the brain, can lead to neurologic deficits or symptoms reflecting damage to specific brain areas.
Risk Factors and Frequency for Cerebellar Infarct (Cerebellar Stroke)
Cerebellar infarcts, which are a type of stroke, make up 2% of all stroke cases but greatly impact the seriousness and death rate of stroke consequences. Research with almost 2000 stroke patients showed that 23% of cerebellar stroke patients sadly passed away, which is almost double the death rate in common cerebral strokes at 12.5%. Strokes that occur in the brainstem have a death rate of 17%.
Signs and Symptoms of Cerebellar Infarct (Cerebellar Stroke)
A cerebellar infarction, or stroke, can often present with symptoms that are hard to distinguish from many other conditions. These symptoms may be confused with issues related to the nervous system, heart, gastrointestinal tract, or other systemic conditions. It’s important to take into account any chest, abdomen, or general body symptoms as these can help exclude other dangerous conditions like trauma, aortic dissection, heart attacks, lung clots, low blood volume, or sepsis.
Often, cerebellar infarctions get misdiagnosed as conditions like vestibular neuronitis, migraines, fainting, high blood pressure emergencies, kidney failure, low blood sugar, or intoxication from alcohol or drugs. Paying attention to the patient’s history is key for risk assessment and treatment planning.
- Symptoms appearing within seconds or minutes suggest benign paroxysmal positional vertigo (BPPV), vasovagal syncope, or arrhythmia.
- Symptoms appearing over minutes to hours may signify hypoglycemia, migraine or psychological causes.
- Symptoms unfolding over hours to days possibly point to labyrinthitis, medication side effects, or cerebellar infarction.
Prolonged symptoms may suggest expansion of a tumor or other mass in the back of the skull (posterior fossa). Triggers of the symptoms, like loud noises or closing the eyes, can provide diagnostic hints. It’s also important to consider risk factors for vascular diseases such as age, smoking, obesity, diabetes, high cholesterol, and high blood pressure.
Close to 75% of patients with a cerebellar infarction report experiencing dizziness, often described as a spinning sensation or feeling like falling towards one side. Many people may also have difficulty walking or may be unable to walk due to poor coordination, regional, or systemic weakness. Over half the patients also report symptoms of nausea or vomiting.
Neurological symptoms in cerebellar infarct patients can manifest as poor coordination of the torso or limbs, eye movement disorders such as double vision or uncontrolled eye movements, and speech disorders. Unlike cerebral strokes, the symptoms usually occur on the same side as the cerebellar stroke. In cases of larger strokes or increased pressure within the skull, patients may present with lethargy, unconsciousness, or heart failure; these symptoms generally indicate a poor prognosis.
Because the symptoms of a cerebellar stroke can be nonspecific, it’s often difficult to diagnose. The presentation relies a lot on where and how large the stroke is. Therefore, a thorough patient history and neurological exam are critical to correctly diagnosing cerebellar lesions.
Testing for Cerebellar Infarct (Cerebellar Stroke)
Magnetic Resonance Imaging (MRI) with a special part known as Diffusion-Weighted Imaging (DWI) is the best technique to detect a stroke in the cerebellum, a part of your brain. It’s good at spotting areas with poor blood flow and damaged tissue, and so helps doctors make a precise diagnosis.
Magnetic Resonance Angiography (MRA), a type of MRI, is particularly useful because it can locate blocked blood vessels and guide treatment, especially when it comes to large blood vessels like the basilar artery.
Unenhanced Computed Tomography (CT) scans can be useful in identifying any bleeding and sometimes, strokes. But, their usefulness is limited when it comes to the cerebellum because nearby bones reduce the quality and accuracy of the images compared to other parts of the brain.
Even so, unenhanced CT scans are often the first choice because they’re more widely available than MRI or MRA and can help to rule out other causes. Enhanced CT scans can be a good option if an MRI is not available.
In combination with a regular neurological exam, a specialized exam called the Head Impulse, Nystagmus, and Test of Skew (HINTS) can be a big help in differentiating conditions like vertigo and spotting a cerebellar stroke, especially if a special test involving the eyes shows unusual behavior.
Laboratory tests, heart monitoring, heart ultrasound, and brain activity recording through an EEG can all contribute in checking for other potential related diseases. These tests are essential and helpful in guiding treatment, whether that treatment is through medications or surgery.
Treatment Options for Cerebellar Infarct (Cerebellar Stroke)
Treatment for cerebellar infarcts, or strokes in the cerebellum, is similar to treatment for other types of strokes. If the stroke is caught within 4.5 hours from when it starts, a medicine called recombinant tissue plasminogen activator (rtPA) might be used. This medicine helps break down the clots causing the stroke.
Diagnosing these strokes early enough to use the rtPA can be tough, so another treatment, thrombectomy, might be used instead. Thrombectomy is where a tiny device is used to physically remove the clot from your blood vessels. While thrombectomy is an option for all stroke patients, it could be more important for those with strokes in the cerebellum since these areas have more tolerance to stroke damage.
In situations where the patient has a clot causing a stroke in a major vessel like the basilar artery, delayed reperfusion therapy, a way to restore blood flow, might be given even after the typical 6-hour window. Brain imaging showing a large mismatch between the area of the brain having poor blood flow and the area damaged by the stroke or a high amount of backup circulation might make doctors act more urgently.
If reperfusion isn’t possible, other blood-thinners like aspirin and clopidogrel might be used. If the stroke was caused by a blood clot that traveled from somewhere else in the body, anticoagulant medicines may also be considered.
Cerebellar strokes often cause brain swelling, especially after the first day. Intensive care monitoring is crucial for these patients. In serious cases needing immediate attention, brain surgery might be needed to relieve swelling or damaged tissue, or temporary treatments to lower pressure in the brain with medications like mannitol or through hyperventilation.
Also, the root cause of the stroke is investigated during hospital admission. Heart monitoring might reveal heart rhythm problems like atrial fibrillation, heart imaging may show a hole in the heart or decreased heart function, and blood tests could show conditions like diabetes or high cholesterol.
As for the use of rtPA, certain criteria must be met. The patient needs to be over 18 years old, have a clinical diagnosis of stroke, and start their treatment within 4.5 hours of when the stroke began. If the history indicates recent head trauma, previous stroke, or specific conditions like an active internal bleeding, or if the patient is already using certain anticoagulants, the treatment might not be advisable due to the risk of complications. All these factors are taken into consideration before starting the treatment.
What else can Cerebellar Infarct (Cerebellar Stroke) be?
When a doctor suspects that a patient may have had a cerebellar infarction, which is a type of stroke affecting the area of the brain known as the cerebellum, they must consider a wide range of possible conditions that could be causing the patient’s symptoms:
- Bleeding within the brain (intracranial hemorrhage)
- Multiple sclerosis (an immune-mediated disease that affects the central nervous system)
- Stroke in the brainstem
- Lacunar stroke (a type of stroke caused by blockage in one of the small arteries inside the brain)
- Stroke in the middle cerebral artery
- Hypertensive encephalopathy (a condition caused by high blood pressure that affects the brain)
- Migraine headache
- Conditions causing an imbalance of vital body chemicals (like hypoglycemia, or drug intoxication)
- Posterior reversible encephalopathy syndrome (a condition that affects the back region of the brain)
- Seizure with post-seizure weakness or paralysis on one side of the body (Todd paralysis)
In order to reach a correct diagnosis, the doctor will have to rule out these alternatives.
What to expect with Cerebellar Infarct (Cerebellar Stroke)
The aftermath of a cerebellar infarction, or a stroke in the cerebellum, is usually similar to that of other types of stroke. The larger the affected area, the more serious health complications and a higher risk of death could be. Thanks to enhancements in early detection and treatment, the overall health complications linked with this condition have been decreasing over time.
Generally, patients recovering from a cerebellar infarction tend to fare better than those recovering from a cerebellar hemorrhage, which is a bleed in the cerebellum.
Possible Complications When Diagnosed with Cerebellar Infarct (Cerebellar Stroke)
If a cerebellar infarction, or stroke in the brain, isn’t diagnosed and treated quickly, it can cause swelling in the brain and potentially lead to death. However, if it’s caught and managed promptly, most people recover well. The most common issue post-recovery is functional debility, which is a decline in physical and mental ability.
There can also be acute issues during hospital stays for cerebellar infarction such as:
- Venous thromboembolism (blood clots that can travel to the lungs)
- Pressure ulcers (sores caused by pressure on the skin)
- Urinary tract infections
- Pneumonia (a lung infection)
Recovery from Cerebellar Infarct (Cerebellar Stroke)
Treatment after a cerebellar stroke, a type of brain stroke, requires a well planned and personalized approach designed to enhance recovery and help the patient regain their independence. After surgeries, such as those to relieve pressure on the brain, patients are closely monitored in a high-care hospital environment.
It’s crucial to start rehab therapy quickly, which often gets underway during the hospital stay, and continues at rehab centers or at home, to make the most of the recovery. A team of various therapists, like physical, occupational, and speech therapists, work together to address the unique challenges created by a cerebellar stroke.
Given the role of the cerebellum in balance and coordination, the rehab program will heavily focus on training these areas. Cognitive therapy may also be needed for issues with memory, attention, and problem-solving. To help with mobility and safety, equipment like canes, walkers, or orthotics might be suggested. Changes might also be made to the patient’s home to make it more supportive and safe.
Emotional support is a key part of rehab, as it helps manage the emotional and mental effects of the stroke on the patient and their caregivers. Regular check-ins with brain and rehab doctors can adjust the patient’s care plan based on their progress and changing needs. A rehab plan that’s tailored to the patient and uses a variety of rehab methods is key to helping recovery and improving life quality after a cerebellar stroke.
Preventing Cerebellar Infarct (Cerebellar Stroke)
Teaching patients about how to prevent future strokes, specifically cerebellar strokes, is incredibly important. This involves sharing information about changes they can make in their everyday life and actions they can take that could lower their chances of having another stroke. Important parts of this education include encouraging patients to quit smoking and stressing the importance of managing any other health conditions they have, like diabetes and high blood pressure.
Patients need to understand how crucial it is to take their medication as prescribed. They should also be encouraged to change their lifestyle in ways that can help prevent future strokes. This could include eating a diet that’s good for their heart and getting regular exercise. Healthcare providers can greatly help patients prevent strokes in the long run and improve their health overall by helping them understand these steps and motivating them to take action.
