Burr-hole cerebellar aspiration for space-occupying cerebellar infarction in two older patients: different clinical pathways to internal decompression

Space-occupying cerebellar infarction may lead to neurological deterioration through posterior fossa swelling, fourth ventricular obstruction, brainstem compression, and hydrocephalus. We describe 2 older women whose different clinical courses led to single-burr-hole cerebellar aspiration under local anesthesia. In case 1, a 71-year-old woman with left cerebellar infarction deteriorated from a Glasgow coma scale (GCS) score of 15 to 13, with ventricular enlargement and compression of the fourth ventricle and brainstem. External ventricular drainage reduced supratentorial ventricular prominence, but posterior fossa mass effect persisted and her GCS score fell to 11. After aspiration, her GCS score improved to 12 immediately, 14 by postoperative day 3, and 15 at discharge. In case 2, a 65-year-old woman had right posterior inferior cerebellar artery occlusion and right cerebellar infarction with hemorrhagic transformation. She initially improved with conservative treatment but later deteriorated to a GCS score of 12 with severe dizziness. Computed tomography showed marked swelling and near-complete effacement of the fourth ventricle. Immediately after direct burr-hole aspiration with cavity drainage, her GCS score improved to 14 and her dizziness decreased. These cases illustrate 2 pathways to limited internal decompression: escalation after cerebrospinal fluid diversion and direct aspiration after delayed posterior fossa deterioration.