Surgical indications and techniques in ischemic cerebellar stroke - results from an international survey

Space-occupying ischemic cerebellar stroke (SOCS) is a neurological emergency, often leading to rapid deterioration due to brainstem compression and hydrocephalus.

The aim of this survey was to characterize surgical indications and techniques in SOCS.

An international survey was conducted, comprising 21 items. The first section inquired about general center characteristics and caseload. Secondly, surgical indications and techniques were investigated. The survey was carried out online via GoogleForms® from October to December 2024.

A total of 216 answers were received. Most respondents worked at an academic hospital (57 %) and were consultants (76 %). A certified stroke unit was present in 169 cases (87 %), and a dedicated neuro-ICU was also common (65 %). While most respondents (189/195, 97 %) performed surgery for SOCS, less than half (93/195, 48 %) had standardized indications for it. Infarct volume was considered when indicating surgery in 136/195 (70 %) of cases, with 30 mL being the most common threshold (62/136, 46 %). Concomitant brainstem infarction did not represent a contraindication for surgery. Suboccipital decompressive craniectomy was the most common surgical technique (155/194, 80 %), but a standardized craniectomy size was seldom (75/155, 48 %). Infarct resection was additionally performed in 125/194, 64 % cases. External ventricular drains (186/194, 86 %), duraplasty (112/194, 52 %), and resection of C1 arch (62/194, 29 %) were variably added to surgery.

Our survey reveals that while surgery is routinely performed for SOCS, neither indications nor techniques are standardized. Evidence must grow stronger to create guidelines to indicate and delineate surgery in SOCS.