Comparison of neurosurgical and medical management options of space-occupying cerebellar infarction.

Abstract

Despite space-occupying cerebellar infarctions (SOCIs) carrying a high morbidity and mortality due to mass effect in the posterior fossa, optimal management remains uncertain: particularly regarding patient selection, timing, and surgical technique. We conducted a systematic review and network meta-analysis to compare outcomes between medical versus surgical management, and to identify prognostic thresholds that may guide treatment. A search of PubMed, Embase, and CENTRAL was performed from database inception through October 30, 2024. Studies were included if they reported outcomes in ≥ 10 patients with SOCI treated with medical management and/or surgical interventions, including suboccipital decompressive craniectomy (SDC), external ventricular drainage (EVD), and necrosectomy. Data extraction and risk-of-bias assessment were performed independently by multiple reviewers. Random-effects meta-analyses and frequentist network meta-analyses were conducted. Primary outcomes were favorable functional status and mortality; secondary outcomes included length of hospital stay. Eighteen studies comprising 754 patients met inclusion criteria. Surgical intervention was associated with superior outcomes in patients with infarct volumes > 51 mL (61.5% favorable outcome vs. 35.0% with medical therapy; p = 0.018) or GCS ≤ 13 (p < 0.05). Among surgical strategies, SDC combined with necrosectomy and an EVD (SDC-N-EVD) conferred the greatest probability of favorable outcome (OR 3.1, 95% CI: 1.18-8.14; p < 0.05), reduced mortality risk, and shortened length of hospitalization. Neither patient age nor surgical timing within 72 h significantly altered outcomes. Surgical management, particularly SDC-N-EVD, was associated with improved outcomes compared to medical therapy alone for SOCI, especially in patients with large infarcts or impaired consciousness. Infarct volume and pre-interventional GCS can provide prognostic thresholds. While the inherent heterogeneity of the data indicates these results should be interpreted with caution, they provide impetus for conducting standardized multicenter prospective studies to validate these observations and establish evidence-based treatment algorithms.