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. 2025 Nov 20;14(22):8229.
doi: 10.3390/jcm14228229.

Diagnostic Pitfalls of CT in Malignant Superior Cerebellar Artery Infarction: Implications for Treatment Decisions and Future Management Strategies

Maria Gollwitzer  1   2 , Baran Atli  1   2 , Vanessa Seiter  1   2 , Tobias Rossmann  1   2 , Eva Horner  1   2 , Anna Hauser  1   2 , Gracija Sardi  1   2 , Verena Sölva  1   2 , Andreas Gruber  1   2   3 , Kathrin Aufschnaiter-Hiessböck  1   2
Affiliations

Diagnostic Pitfalls of CT in Malignant Superior Cerebellar Artery Infarction: Implications for Treatment Decisions and Future Management Strategies

Maria Gollwitzer et al. J Clin Med. .

Abstract

Background/Objectives: Superior cerebellar artery (SCA) infarction is a rare but clinically significant subtype of posterior circulation stroke. Extensive swelling in the SCA territory may cause downward brainstem compression and appear as brainstem hypodensity on computed tomography, potentially leading to premature treatment withdrawal. Methods: We report the case of a 50-year-old woman with acute SCA-territory infarction (NIHSS = 7) presenting with vertigo, dysphagia, dysarthria, and diplopia. Initial computed tomography suggested extensive brainstem infarction, prompting withdrawal of treatment. Diffusion-weighted MRI revealed reversible edema with brainstem sparing. The patient underwent suboccipital decompressive craniectomy and ventricular drainage with favorable neurological recovery. In addition, a systematic literature search was conducted according to PRISMA 2020 guidelines in PubMed, Web of Science, and Scopus (studies published since 1 January 2015). Fifteen studies met predefined eligibility criteria. Results: Magnetic resonance imaging findings were decisive in avoiding a falsely dismal prognosis and inappropriate withdrawal of care. Across the literature, infarct volume (>30-35 mL), brainstem involvement and bilateral cerebellar infarction emerged as key predictors of malignant course. Early decompressive surgery was consistently associated with improved survival, though functional outcomes varied. Fast magnetic resonance imaging techniques and volumetric imaging improved risk stratification and surgical decision-making. Conclusions: SCA infarction can mimic brainstem infarction on computed tomography due to secondary compression rather than true ischemia. Magnetic resonance imaging is essential to guide treatment and prevent avoidable mortality. Multimodal imaging combined with interdisciplinary management allows for accurate prognostication and optimized surgical timing in malignant SCA infarction.

Keywords: CT; MRI; PRISMA; decompressive craniectomy; posterior fossa stroke; prognostic imaging; stroke.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
(A) Diffusion-weighted MRI on admission showing acute ischemic infarction of the right cerebellar hemisphere and vermis. (B) DSA demonstrating occlusion of the right SCA with preserved patency of the basilar tip.
Figure 2
Figure 2
(A,B) Follow-up CT revealing an expanding infarct of the right cerebellum with mass effect and apparent hypodensity in the pons, midbrain and diencephalon, raising suspicion of brainstem infarction. (C) Axial diffusion weighted image obtained after suspicious CT findings excluding brainstem infarction and demonstrating predominantly cerebellar edema. (D) Postoperative CT scan following suboccipital decompression, partial cerebellar tissue resection and ventricular drainage.
Figure 3
Figure 3
PRISMA flow diagram illustrating the study selection process for the structured literature review on malignant SCA infarction.
See this image and copyright information in PMC

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