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. 2024 Feb 26;81(4):384-393.
doi: 10.1001/jamaneurol.2023.5773. Online ahead of print.

Functional Outcomes in Conservatively vs Surgically Treated Cerebellar Infarcts

Sae-Yeon Won  1 , Silvia Hernández-Durán  2 , Bedjan Behmanesh  1 , Joshua D Bernstock  3 , Marcus Czabanka  4 , Nazife Dinc  5 , Daniel Dubinski  1 , Thomas M Freiman  1 , Albrecht Günther  6 , Kara Hellmuth  1 , Eva Herrmann  7 , Juergen Konczalla  4 , Ilko Maier  8 , Ruzanna Melkonian  5 , Dorothee Mielke  2 , Paul Naser  9 , Veit Rohde  2 , Christian Senft  5 , Alexander Storch  10 , Andreas Unterberg  9 , Johannes Walter  9 , Uwe Walter  10 , Matthias Wittstock  10 , Jan Hendrik Schaefer  11 , Florian Gessler  1
Affiliations

Functional Outcomes in Conservatively vs Surgically Treated Cerebellar Infarcts

Sae-Yeon Won et al. JAMA Neurol. .

Abstract

Importance: According to the current American Heart Association/American Stroke Association guidelines, decompressive surgery is indicated in patients with cerebellar infarcts that demonstrate severe cerebellar swelling. However, there is no universal definition of swelling and/or infarct volume(s) available to support a decision for surgery.

Objective: To evaluate functional outcomes in surgically compared with conservatively managed patients with cerebellar infarcts.

Design, setting, and participants: In this retrospective multicenter cohort study, patients with cerebellar infarcts treated at 5 tertiary referral hospitals or stroke centers within Germany between 2008 and 2021 were included. Data were analyzed from November 2020 to November 2023.

Exposures: Surgical treatment (ie, posterior fossa decompression plus standard of care) vs conservative management (ie, medical standard of care).

Main outcomes and measures: The primary outcome examined was functional status evaluated by the modified Rankin Scale (mRS) at discharge and 1-year follow-up. Secondary outcomes included the predicted probabilities for favorable outcome (mRS score of 0 to 3) stratified by infarct volumes or Glasgow Coma Scale score at admission and treatment modality. Analyses included propensity score matching, with adjustments for age, sex, Glasgow Coma Scale score at admission, brainstem involvement, and infarct volume.

Results: Of 531 included patients with cerebellar infarcts, 301 (57%) were male, and the mean (SD) age was 68 (14.4) years. After propensity score matching, a total of 71 patients received surgical treatment and 71 patients conservative treatment. There was no significant difference in favorable outcomes (ie, mRS score of 0 to 3) at discharge for those treated surgically vs conservatively (47 [66%] vs 45 [65%]; odds ratio, 1.1; 95% CI, 0.5-2.2; P > .99) or at follow-up (35 [73%] vs 33 [61%]; odds ratio, 1.8; 95% CI, 0.7-4.2; P > .99). In patients with cerebellar infarct volumes of 35 mL or greater, surgical treatment was associated with a significant improvement in favorable outcomes at 1-year follow-up (38 [61%] vs 3 [25%]; odds ratio, 4.8; 95% CI, 1.2-19.3; P = .03), while conservative treatment was associated with favorable outcomes at 1-year follow-up in patients with infarct volumes of less than 25 mL (2 [34%] vs 218 [74%]; odds ratio, 0.2; 95% CI, 0-1.0; P = .047).

Conclusions and relevance: Overall, surgery was not associated with improved outcomes compared with conservative management in patients with cerebellar infarcts. However, when stratifying based on infarct volume, surgical treatment appeared to be beneficial in patients with larger infarct volumes, while conservative management appeared favorable in patients with smaller infarct volumes.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Bernstock has an equity position in Treovir and UpFront Diagnostics; is a cofounder of Centile Bioscience; and serves on the scientific advisory board for NeuroX1. Dr Günther reported personal fees from Merz Pharma, Ipsen Pharma, Boehringer Ingelheim, Occlutech, and Daiichi Sankyo outside the submitted work. Dr Mielke reported serving on advisory committees for Medtronic and Imperial Petroleum outside the submitted work. Dr Senft reported grants from Novocure as well as personal fees from Stryker, Brainlab, and Bayer outside the submitted work. Dr U. Walter reported grants from Merz Pharmaceuticals; personal fees from Amarin, Amgen, Bristol Myers Squibb, and Daiichi Sankyo; and royalties from the European Journal of Ultrasound outside the submitted work. Dr Schaefer reported nonfinancial support from Bayer AG outside the submitted work. Dr Gessler reported personal fees from Aesculap, Signus, and AstraZeneca outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flowchart of Study Population and Propensity Score Matching
Patients were identified from the University Medicine Rostock (2015-2021), University Hospital Göttingen (2010-2018), University Hospital Frankfurt (2014-2020), University Hospital Heidelberg (2015-2021), and University Hospital Jena (2008-2017).
Figure 2.
Figure 2.. Functional Outcomes at Discharge and 1-Year Follow-Up
Functional outcome in the propensity score–matched cohort at discharge (A) and at 1-year follow-up (B). There was no significant difference between patients receiving conservative or surgical treatment.
Figure 3.
Figure 3.. Outcome Association of the Intervention With Cerebellar Infarct Volumes
A, Regression curve and confidence region from a logistic regression analysis estimating the probability to acquire favorable outcome (modified Rankin Scale [mRS] score of 0 to 3) with respect to infarct volume and treatment with interactions. As a surrogate marker for the binary outcome, points are shown for predicted probabilities from a larger regression model using adjustments by the following variables: age, sex, Glasgow Coma Scale score at admission, infarct volume, brainstem involvement, and treatment with interaction between infarct volume and treatment. The crossing point of the regression lines was used for the evaluation of cutoff values. B, Validation of predicted associations based on observed data points graphically depicted as adjusted odds ratio estimates for surgical posterior fossa decompression vs conservative treatment with favorable outcome (mRS score of 0 to 3). Adjusted odds ratio estimates were calculated within specific cerebellar infarct volume frames (15, 25, 35, 45, 60, and 90 mL). Mean estimates are shown with 95% CIs.
Figure 4.
Figure 4.. Outcome Association of the Intervention With Glasgow Coma Scale (GCS) Score and Cerebellar Infarct Volumes
A and C, Regression curve and confidence regions for subgroups of patients stratified by GCS score at admission (less than 14 vs 14 or greater). B and D, Validation of predicted associations based on observed data points graphically depicted as adjusted odds ratio estimates for surgical posterior fossa decompression vs conservative treatment with favorable outcome (modified Rankin Scale [mRS] score of 0 to 3) stratified by GCS score at admission. Adjusted OR estimates were calculated within specific cerebellar infarct volume frames (15, 25, 35, 45, 60, and 90 mL). Mean estimates are shown with 95% CIs.
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