Suboccipital Decompressive Craniectomy for Malignant Cerebellar Infarction: A Single-Centre Retrospective Study

Malignant cerebellar infarction is an uncommon but life-threatening form of ischemic stroke. Progressive oedema within the posterior fossa may lead to obstructive hydrocephalus, brainstem compression, and rapid neurological deterioration. Suboccipital decompressive craniectomy (SDC), usually combined with external ventricular drainage (EVD), is regarded as the standard rescue procedure, although the role of additional necrosectomy remains debated. We retrospectively reviewed all patients who underwent surgical treatment for malignant cerebellar infarction at our department between 2010 and 2022. Functional outcome was assessed using the modified Rankin Scale (mRS) at 3 months and 1 year. We descriptively evaluated outcomes according to the surgical strategy used: SDC + EVD alone or SDC + EVD with additional necrosectomy. Because the decision to perform necrosectomy was based on intraoperative findings and surgeon judgement rather than predefined allocation criteria, comparisons between the groups were considered exploratory. Thirty-five patients were included (22 men, 13 women; mean age 59 years). Fifteen patients underwent SDC + EVD and 20 underwent SDC + EVD + necrosectomy. At 1 year, favourable outcome was observed in 6/15 patients (40%) treated with SDC + EVD and in 11/20 patients (55%) treated with additional necrosectomy. Median 1-year mRS was 4 and 3, respectively. These unadjusted differences were not statistically significant and cannot establish superiority of either strategy because of the retrospective, non-randomized treatment allocation. SDC remains a life-saving intervention in malignant cerebellar infarction. In this cohort, patients undergoing additional necrosectomy had numerically more favourable outcomes; however, the groups were not directly comparable because treatment selection was based on clinical, radiological, and intraoperative findings. Consequently, no conclusion regarding the superiority or independent effect of necrosectomy can be drawn from these data.