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      Neurosurgical management of massive cerebellar infarct outcome in 53 patients

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          Abstract

          Background:

          Massive ischemic cerebellar infarct (MICI) is a main source of stroke, which can lead to severe morbidity and mortality. There is no consensus in medical literature for the management of MICI. The choice is made between placing an external ventricular drainage, suboccipital decompressive craniectomy, and removal of necrotic tissue or conservative treatment. There are not many prospective studies, done on this subject.

          Methods:

          We retrospectively analyzed the clinical features, and imaging studies of 53 patients with MICI who had been treated by surgery or conservative treatment between January 2000 and December 2008 at the Department of Neurosurgery of the general hospital of Fort de France in Martinique. A total of 25 patients underwent surgery and 28 were treated medically.

          Results:

          The results show significantly better outcomes in the operated patients compared with the patients treated medically; Operated comatose patients demonstrated significant improvement in their Glasgow coma score (GCS) score with only two deaths. Whereas, nonoperated comatose patients lost points in their GCS with four deaths.

          Conclusion:

          The results of our study suggest that surgery may be an effective procedure and quite helpful for MICI in majority of cases.

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          Most cited references 21

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          Cerebellar stroke without motor deficit: clinical evidence for motor and non-motor domains within the human cerebellum.

          To determine whether there are non-motor regions of cerebellum in which sizeable infarcts have little or no impact on motor control. We evaluated motor deficits in patients following cerebellar stroke using a modified version of the International Cooperative Ataxia Rating Scale (MICARS). Lesion location was determined using magnetic resonance imaging (MRI) and computerized axial tomography (CT). Patients were grouped by stroke location-Group I, stroke within the anterior lobe (lobules I-V); Group 2, anterior lobe and lobule VI; Group 3, posterior lobe (lobules VI-IX; including flocculonodular lobe, lobule X); Group 4, posterior lobe but excluding lobule VI (i.e. lobules VII-X); Group 5, stroke within anterior lobe plus posterior lobe. Thirty-nine patients were examined 8.0+/-6.0 days following stroke. There were no Group 1 patients. As mean MICARS scores for Groups 2 through 5 differed significantly (one-way analysis of variance, F(3,35)=10.9, P=0.000 03), post hoc Tukey's least significant difference tests were used to compare individual groups. Group 2 MICARS scores (n=6; mean+/-SD, 20.2+/-6.9) differed from Group 3 (n=6; 7.2+/-3.8; P=0.01) and Group 4 (n=13; 2.5+/-2.0; P=0.000 02); Group 5 (n=14; 18.6+/-12.8) also differed from Group 3 (P=0.009) and Group 4 (P=0.000 02). There were no differences between Groups 2 and 5 (P=0.71), or between Group 3 and Group 4 (P=0.273). However, Group 3 differed from Group 4 when analyzed with a two-sample t-test unadjusted for multiple comparisons (P=0.03). Thus, the cerebellar motor syndrome resulted from stroke in the anterior lobe, but not from stroke in lobules VII-X (Groups 2 plus 5, n=20, MICARS 19.1+/-11.2, vs. Group 4; P=0.000 002). Strokes involving lobule VI produced minimal motor impairment. These findings demonstrate that cerebellar stroke does not always result in motor impairment, and they provide clinical evidence for topographic organization of motor versus nonmotor functions in the human cerebellum.
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            Diagnosis and initial management of cerebellar infarction.

            Cerebellar infarction is an important cause of stroke that often presents with common and non-specific symptoms such as dizziness, nausea and vomiting, unsteady gait, and headache. Accurate diagnosis frequently relies on careful attention to patients' coordination, gait, and eye movements--components of the neurological physical examination that are sometimes omitted or abridged if cerebellar stroke is not specifically being considered. The differential diagnosis is broad, and includes many common and benign causes. Furthermore, early-stage posterior fossa ischaemia is rarely seen with brain CT--the most commonly available initial imaging test that is used for stroke. Insufficient examination and imaging can result in misdiagnosis. However, early correct diagnosis is crucial to help prevent treatable but potentially fatal complications, such as brainstem compression and obstructive hydrocephalus. The identification and treatment of the underlying vascular lesions at an early stage can also prevent subsequent occurrences of stroke and improve patients' outcomes. Here, we review the clinical presentation of cerebellar infarction, from diagnosis and misdiagnosis to patients' monitoring, treatment, and potential complications.
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              Stroke in patients with dengue.

              Central nervous system infections are one of the common causes of stroke in developing countries. Stroke after dengue is uncommon. A total of 1148 dengue cases were seen in a tertiary referral hospital during the epidemic from September to November 2008. We present 3 patients who had stroke caused by dengue. The first patient was a 45-year-old woman with dengue hemorrhagic fever who developed sudden right arm and leg weakness. Magnetic resonance imaging (MRI) revealed multiple hemorrhagic foci in the left parietal and temporal lobes. The second patient was a 35-year-old man who developed fever that was followed by altered sensorium and quadriparesis. MRI showed bilateral cerebellar hemorrhages with edema, obstructive hydrocephalus, and multiple watershed infarcts. The third patient was a 70-year-old woman who presented with giddiness for 2 days followed by sudden weakness of the left side of the body. She developed fever after admission. MRI showed infarct in the right parietal lobe. All the patients had low platelet count and one patient died. Dengue might be an important cause of stroke in epidemic regions when patients present with fever, focal neurologic deficits, and encephalopathy. Copyright (c) 2010 National Stroke Association. Published by Elsevier Inc. All rights reserved.
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                Author and article information

                Contributors
                Journal
                Surg Neurol Int
                Surg Neurol Int
                SNI
                Surgical Neurology International
                Medknow Publications & Media Pvt Ltd (India )
                2229-5097
                2152-7806
                2013
                27 February 2013
                : 4
                Affiliations
                Department of Neurosurgery, General Hospital of Cayenne, French Guiana
                Author notes
                [* ]Corresponding author
                Article
                SNI-4-28
                10.4103/2152-7806.107906
                3604818
                23532804
                Copyright: © 2013 Mostofi K

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Categories
                Fundamental Neurosurgery

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