Cerebellar Infarct Accompanied by Acute Hydrocephalus: A Case Report of 1-Year Follow-up in Rural Neurosurgical Practice

Abstract

Cerebellar infarctions account for about 2-3% of all ischemic strokes, and acute hydrocephalus due to brainstem compression or compression of the cerebrospinal fluid (CSF) flows is a rare manifestation from a stroke of the posterior circulation. The condition is considered one of the most life-threatening complications in cerebellar infarct due to the possibility of transforaminal and upward transtentorial herniation. The management of patients with cerebellar infarct is challenging, because the patient usually presents with non-specific signs and symptoms until the patient loses consciousness. Standard management should be provided by a stroke unit team or neuro-intensive care unit. The precision timing of treatment and evaluation with close observation is crucial, even when there is no life-threatening condition at initial presentation, but sometimes it is difficult to fulfill in rural areas due to the substandard facilities and lack of resources. Here we report a case of cerebellar infarct with massive edema in association with acute hydrocephalus with the progressive deterioration that happened in a rural area. A 59-year-old male patient complained about an episode of sudden headache which was followed by dizziness, vomiting, and loss of balance. A head non-contrast CT scan in the emergency room (ER) is performed 4 hours after ictus, showed a slightly hypodense lesion in the left cerebellum, without accompanying edema and hydrocephalus. The patient was then managed conservatively in the ward. In the next 36 hours, his consciousness level was reduced and a head CT scan evaluation showed the development of massive edema of cerebellar infarct with acute hydrocephalus. The patient underwent an emergency surgical procedure with suboccipital decompressive craniectomy (SDC) with strokectomy, expanded duraplasty, and ventricular drainage (ventriculoperitoneal shunt). Satisfactory results with rapid resolution of GCS was seen at daily follow-up after surgery. A 1-year follow-up also showed remarkable outcomes.