Outcomes of patients with posterior fossa stroke admitted to the ICU: an observational retrospective cohort

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Many patients require intensive care unit (ICU) admission and might require surgical interventions, such as suboccipital decompressive craniectomy (SDC). The objective of this study was to describe the clinical chacteristics, management and outcomes of posterior fosa stroke patients admitted to ICU and to identify risk factors associated with outcomes and surgical management Methods This is a retrospective monocentric study of patients that were admitted to a tertiary hospital neuro-ICU for a cerebellar stroke. Clinical characteristics, surgical management and outcome were retrieved from medical files. Good functionnal outcome, defined as a mRS score < 2, was assesed at one year. Results 53 patients were included. At one year follow-up, 22/53 (41.5%) of patients had a good functional outcome. 26/53 (49%) were treated by SDC and 26/53 (49.1%) had an EVD. ICU mortality was 23%, with a one-year mortality rate of 32%. Factors associated with SDC were volume of the lesion, brainstem compression on neuroimaging and level of consciousness. We found no association between 1-year functional outcome (mRS) and SDC. Younger age (under 50 years old), higher level of consciousness on admission, and absence of signs of brainstem compression were associated with a better outcome. Conclusion We found that patient admitted in ICU for posterior fossa vascular space occupying lesions had a poor one-year functional outcome with no benefit observed from SDC. SDC should be adequately evaluated in further interventional randomized trials. Cerebellar stroke Haemorrhagic stroke Intra-Cranial Space Occupying Lesion Ischemic stroke Posterior Fossa Sub-Occipital Decompressive Craniectomy Figures Figure 1 Figure 2 Figure 2 INTRODUCTION Strokes occurring in the posterior fossa represent a sub-group among cerebro-vascular events with specific complications, management and outcomes. Cerebellar hematomas account for 10% of all intracranial hemorrhage whereas cerebellar infarcts only 1–4% of all brain ischemic strokes ( 1 ). They represent nearly 500 000 patients per year worldwide and some of them will require admission to intensive care units ( 2 ). Indeed, ICU admitted severe cerebro-vascular accidents are associated with a grim prognosis of 30,9% ( 3 ) and 9–39% mortality ( 4 ) for cerebellar hematoma and posterior fossa ischemia respectively. Patients with cerebellar strokes should be monitored closely because of the high risk of deterioration in this context of intracranial space-occupying lesions. Neuroimaging plays here a major role in the management of Intensive Care Unit (ICU) patients care as it allows to target the appropriate medical or surgical therapy. The optimal management of posterior fossa space occupying lesions is debated. Surgical treatment, either suboccipital decompressive craniectomy (SDC) or external ventricular drainage (EVD), has become the recommended care for large cerebellar stroke, hemorrhage or infarcts. Recent guidelines from the American Stroke Association ( 5 ) and European Stroke Organization ( 6 ) recommend decompression in patients with clinical deterioration, signs of brainstem compression and/or hydrocephalus. However, international recommanations are low evidence based and remain weak as no prospective randomized trial has been pursued. In order to better document this issue, we conducted a retrospective study to describe the clinical chacteristics, management and outcome of posterior fosa stroke patients admitted to ICU and identify risk factors associated with outcome and surgical management. METHODS Study Design We conducted a monocentric retrospective study of patients admitted to the surgical ICU of a tertiary care hospital in Paris, France. Ethics Approval and Consent to Participate This study was approved by the Institutional Review Board “Comité d’Éthique de la Recherche” (CER) Paris Nord (IRB 00006477, HUPNVS, Paris 7 University, AP-HP). Given the retrospective design of the study, informed consent was obtained whenever possible from patients or, if they were unable to consent, from their next-of-kin, in accordance with French regulations. All participants (or their legally authorized representatives) were informed about the study and could refuse inclusion. Human Ethics and Consent to Participate declarations The authors confirm that the study was conducted in accordance with institutional ethical standards and with the principles of the Declaration of Helsinki. Patient selection We included all adults admitted to Intensive Care Unit (ICU) in Lariboisière Hospital in Paris, from January 2016 to December 2021, for a space-occupying cerebellar stroke. A space occupying lesion (7) was defined as an acute cerebellar ischemic or hemorrhagic stroke, with either a radiological mass effect (compression of the fourth ventricle, compression of the quadrigeminal cistern, dilatation of the inferior horn of the lateral ventricle or downward cerebellar herniation) or a decreased level of consciousness (Glasgow Coma Scale (GCS) < 13). We excluded patients under 18 years old as well as intracranial space occupying lesions (ICSOL) of tumoral, traumatic or infectious nature. Vascular lesions such as subarachnoid hemorrhage or arterioveinous malformation were not included either. Data collection We retrospectively collected epidemiological variables (sex, age, cardiovascular risk factors) as well as the characteristics of the stroke (ischemic or hemorrhagic, volume) from medical files. Clinical data were analyzed, until 48 hours from onset of symptoms: Glasgow Coma Scale (GCS), cerebellar syndrome (ataxia, vertigo and nausea, nystagmus), clinical signs of intracranial hypertension (nausea and vomiting, headache, blurred vision, confusion), signs of brainstem compression such as cranial nerve deficit, including pupilar abnormalities (anisocoria or mydriasis), motor deficit. If patient was sedated on admission, the last medical exam was used. Clinical deterioration during the first 48 hours of symptoms, defined as the loss of >2 points of GCS, was specified. Neuroradiological images were analyzed by a senior radiologist (JP.G.). The latest brain imaging available before any eventual surgery was selected: Computed Tomography (CT) Scans for hemorrhage and Magnetic Resonance Imaging (MRI) for ischemic strokes (CT if not available). Volume of bleed or infarct, as well as the size of the surrounding oedema, were calculated using Carestream software (Rochester, New York, USA) and semi-automatic contouring. For ischemic strokes, the swelling was the difference of volume between FLAIR and diffusion weighted sequences in MRI. For hematomas, it was the hypodensity surrounding spontaneous hyperdensity. According to international recommandations (5), intracranial hemorrhage was considerd to be of large volume if of more than 15cm3. Mass effect of the space-occupying stroke was defined according to the scoring system of Jauss et al (8), composed of 3 separated items: compression of the fourth ventricle, compression of the quadrigeminal cistern and dilatation of the inferior horn of the lateral ventricle. The presence of one or more of those signs, or of downward cerebellar herniation, suggests an increasing pressure in the posterior fossa. Hydrocephalus was analyzed separately, as it is a direct consequence of a fourth ventricle compression or intraventricular hemorrhage. All patients were provided medical care according to international and local protocols. This involved optimizing cerebral perfusion pressure by managing factors such as hypertension, temperature, hyper or hypocapnia, as well as addressing ionic and metabolic imbalances. The decisions to perform Suboccipital Decompressive Craniectomy (SDC) and Extraventricular Drainage (EVD) insertion were made after a multidisciplinary discussion between neurosurgical and neuro-ICU teams. The SDC was systematically bilateral with ablation of the posterior arch of the atlas. In cases of hemorrhagic lesions treated with SDC, a necrosectomy (partial or total) could be performed as a complementary intervention. Alternatively, for cases not requiring surgical decompression, an EVD could be proposed. Outcomes The outcome assessment was the modified Rankin scale (mRS) score, ranging from 0 to 6. We defined patients with mRS ≤ 2 having a good outcome. This assessment was performed at discharge, at follow up visits and until a year after day of admission. For patients that passed away in ICU, the cause of death (brain death or withdrawal of life sustaining therapies) was specified. Data analysis Results are provided in both absolute values and percentages for categorical variables and in median and interquartile range for continuous variables. In univariable analyses, group comparisons were conducted using Fisher's test for categorical variables and the Wilcoxon test for continuous variables. In multivariable analyses, factors associated with suboccipital decompressive craniectomy, and prognosis were tested in a binomial logistic regression model. Variables were selected from those with a p-value < 0.05 in univariable analysis. The total volume of the lesion, a commonly known prognostic factor, was integrated into the multivariable analysis. The mRS at discharge from ICU predicting the one-year prognosis was determined using the Youden method. Confidence intervals were determined through stratified resampling based on the simulation of 2000 samples. Statistical analysis was conducted using R software version 4.3.0 (R Core Team, 2023, R Foundation for Statistical Computing, Vienna, Austria, https://www.R-project.org), and the packages TableOne version 0.13.2 and pROC version 1.18.0. A p-value < 0.05 was considered statistically significant RESULTS 53 patients have been admitted to ICU between 2017 and 2021 with a cerebellar stroke. 26 patients (49%) of them underwent neurosurgery with a suboccipital decompressive craniectomy. Seven (13%) had EVD only. Baseline Characteristics, Clinical exam, Neuroimaging Patient demographics are presented in Table 1. 55% (n = 29) of patients were male, with a median age of 57 years old. Most of them have at least one cardiovascular risk factor (77%). Admission median GCS was 14 [IQR 9, 15] and 30% of patients experienced clinical deterioration within 48 hours. The median lowest GCS was at 12 [IQR 6, 14]. 23% (n = 12) of patients presented with signs of intracranial hypertension, sometimes overlapping with cerebellar syndrome, observed in 53% (28). 26 patients (49%) had indirect signs of brainstem compression with 18 (34%) motor deficit and 18 cranial nerve deficit (with 6 pupilar abnormalities). Median total volume was 41.5 [IQR 13.5, 72.5] cm2 with 64% (n = 34) of signs of posterior fossa hypertension (either cistern or 4th ventricle compression or tonsillar herniation) and 33 out of 53 (62%) hydrocephalus. Decompressive Surgery Out of 53 critically ill patients, 26 (49%) were treated by SDC and 19 of them received additional EVD. Patients that underwent decompressive surgery had more neurological failure with 70% (18/26) of patients with a GCS < 13 against only 34% (9/27) in the other group (Table 2). Moreover, the volume of the stroke (lesion and oedema) was significatively more important in the craniectomy group with a total of 57 cm3 (IQR [35, 82]) against 18 cm3 [7, 65]. Neuroimaging also showed more indirect signs of posterior fossa hypertension (88% in the craniectomy group vs 41%, p < 0.001) and hydrocephalus (81% in the SDC group vs 44% if SDC was not performed, p = 0.01). In multivariate analysis, independent risk factors associated with decompressive craniectomy were the volume of the lesion, brainstem compression on neuroimaging as well as level of consciousness (Table 3) but not hydrocephalus. Long-Term Functional Outcome Mortality rate in ICU was 23% (n = 12) with 4 brain deaths and 8 linked to a withdrawal of life sustaining therapy (WLST) (Table 4). At 1 year, mortality rate was 32% (17/53). At one year follow-up, 11/26 (42%) of patients with SDC had a good functional outcome with a mRS score between 0 and 2, against 41% in the medical strategy group (Figure 1). We found no statistical (p = 0.777) difference on functional outcome 1 year after admission between patients that underwent decompressive surgery and those who did not (Table 5). However, patients with bad outcome had worst level of consciousness (55% of admission GCS 2) were older age (after 50 years old), lower level of consciousness at admission, and clinical signs of brainstem compression (Table 6). Neither surgical treatment, volume of lesion nor radiological signs of brainstem compression and hydrocephalus were correlated to outcome. Moreover, there is no difference in long term prognosis between ischemic and hemorrhagic stroke. Evolution of mRS over time is presented in Figure 2. We observe little change throughout the first year, with only 28% of patients initially dependent at discharge (mRS 3 to 5) that gained a satisfactory level of autonomy (mRS 0-2) during the first year. Furthermore, only 7 out of 42 patients (16.7%) that were discharged from ICU experienced an improvement in functional independence, advancing by more than one mRS category over the course of the year. 76% of these patients remain stable, with an evolution (positive or otherwise) of ≤ 1 Rankin stage. No major differences were observed between ischemic or haemorrhagic strokes (Supp Figure 1 Appendix). DISCUSSION In this retrospective study, we found that patients admitted in ICU for cerebellar space occupying strokes had poor one-year prognosis, with around a third of good functional outcome. SDC was not associated with any benefit. Risk factors for poor functional outcome included age, GCS on admission and clinical signs of brainstem compression. SDC were more frequently performed in patients with important stroke volume (more than 15 cm3), radiological signs of brainstem compression and a low level of consciousness within the first 48 hours that had poor long term predicted prognosis. Nonetheless, the role of SDC should be adequately evaluated in further interventional randomized trials. Previous studies investigated the impact of SDC on patient outcome with discordant results. A prospective study conducted by Jauss (8) found that surgical patients had a lower level of consciousness upon admission, more clinical signs of brainstem compression as well as more radiological mass effet. Hackenberg (9) reaches the same conclusion when he compared the 6 months prognosis of 85 patients with hemorrhagic cerebellar stroke between patients that have been operated on (SDC and/or EVD) and those that were treated medically. Patients that underwent SDC had a lower preoperative GCS and larger hematomas. Nevertheless, no association between surgery and pronosis was found. Using propensity score, they showed that craniectomy was associated with a lower mortality and functional outcome 6 months after surgery. The differences with our current results could be due to differences in surgery (systematic addition of haematoma evacuation to SDC), types of strokes as we included both ischemic and haemmorhagic lesions, patients characteristics as patient presented here are about 10 years younger than in most studies, and a clinical evaluation at one year instead of 6 month in the study by Hackenberg et al. More recently, Won and al (10) conducted a comparison between the one-year prognosis of ischemic cerebellar stroke patients who underwent suboccipital decompressive craniectomy and those who did not. Despite initial differences on both GCS score and infarct volume, they found no statistical difference in long term functional prognosis between these two groups. Interestingly, their study revealed that strokes with a volume exceeding 35mL had a better functional outcome (mRS 0-3) with surgical intervention, while those with a volume of less than 25mL tended to benefit from conservative treatment. Our approach was not limited to the etiology either ischemia or haemorrhage, of the ICSOL, but tried to capture the picture of posterior fossa intracranial hypertension as a whole for which SDC could represent an interesting therapeutic option. Due to anatomical proximity to the brainstem, these lesions are at risk of compressing vital structures, making it a more potent prognostic factor than the neuronal lesion itself. As seen in other types of strokes, the timing and the selection of patients for surgery is crucial and difficult to determine. With recent successes in adeaquately selected patients, minimally invasive surgery appears to be a promising therapeutic (11) in the management of these strokes. Recent guidelines for haemorragic strokes recommend to perform craniotomy if patient degrades clinically, in case of brainstem compression or if the volume of the hematoma is over 15 mL. SDC are not evoked in the guidelines while it may have some advantages with reduction of posterior fossa intracranial hypertension without entering brain tissue. The proper contribution of SDC and hematoma evacuation, alone or combined, remain to be evaluated. In ischemic stroke of the posterior fossa, expert stated that SDC could be performed in patient with brainstem compression but this recommendation was poorly evidenced. Limitations Our study suffers several limitations. First, the retrospective design of the study likely causes a selection bias of patients, both in ICU admission and surgical indication. Those who did not undergo SDC were less severe or were already limited for surgery due to catastrophic stroke prognosis. Second, as discussed previously, we included patients with both hemorrhagic and ischemic strokes, that have different underlying pathophysiology, clinical presentation and treatment. However, the notion of Intra-Cranial Space Occupying Lesion allows grouping these two diseases, both of which, in the acute phase of intensive care, share a short-term prognosis linked to this increased pressure in the posterior fossa. Third, the study could be underpowered due an insufficient number of patients. Fourth, few studies investigated functional outcome at one year, making the comparisons between studies difficult, but having a good grasp on patient overall status with our 12-month evaluation. Fifth, the monocentric design limits the generalization of our results. Last, new mini-invasive interventions such as necrosectomy are currently under investigation and could represent a new alternative to SDC (12). CONCLUSION To conclude, In the present study, we found that patient admitted in ICU for posterior fossa vascular space occupying lesions had a poor one-year functional outcome with no benefit observed with SDC. SDC should be adequately evaluated in further interventional randomized trials. Abbreviations CSF Cerebro Spinal Fluid CT Computed Tomography EVD Extra-Ventricular Drainage GCS Glasgow Coma Scale ICSOL Intra-Cranial Space Occupying Lesion ICU Intensive Care Unit MRI Magnetic Resonance Imaging mRS modified Rankin Scale SDC Sub-Occipital Decompressive Craniectomy WLST Withdrawal of Life Sustaining Therapy Declarations Funding : This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Disclosures : The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. References Venti M. Cerebellar Infarcts and Hemorrhages. In: Paciaroni M, Agnelli G, Caso V, Bogousslavsky J, éditeurs. Frontiers of Neurology and Neuroscience [Internet]. S., Karger AG (2012) [cité 11 déc 2022]. pp. 171–5. Disponible sur: https://www.karger.com/Article/FullText/333635 Diringer MN, Edwards DF (2001) Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med mars 29(3):635–640 Witsch J, Neugebauer H, Zweckberger K, Jüttler E (2013) Primary cerebellar haemorrhage: Complications, treatment and outcome. Clin Neurol Neurosurg juill 115(7):863–869 Won SY, Melkonian R, Behmanesh B, Bernstock JD, Czabanka M, Dubinski D et al (2023) Cerebellar Stroke Score and Grading Scale for the Prediction of Mortality and Outcomes in Ischemic Cerebellar Stroke. Stroke oct 54(10):2569–2575 Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN et al 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke [Internet]. juill 2022 [cité 30 avr 2023];53(7). Disponible sur: https://www.ahajournals.org/doi/ 10.1161/STR.0000000000000407 Van der Worp HB, Hofmeijer J, Jüttler E, Lal A, Michel P, Santalucia P et al (2021) European Stroke Organisation (ESO) guidelines on the management of space-occupying brain infarction. Eur Stroke J juin 6(2):XC–CX Neelakantaiah AH Morphological Patterns of Intracranial Lesions in a Tertiary Care Hospital in North Karnataka: A Clinicopathological and Immunohistochemical Study. J Clin Diagn Res [Internet]. 2016 [cité 26 nov 2023]; Disponible sur: http://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2016&volume=10&issue=8&page=EC01&issn=0973-709x&id=8237 Jauss M, Krieger D, Hornig C, Schramm J, Busse O (1999) Surgical and medical management of patients with massive cerebellar infarctions: results of the German-Austrian Cerebellar Infarction Study. J Neurol 29 avr 246(4):257–264 Hackenberg KAM, Unterberg AW, Jung CS, Bösel J, Schönenberger S, Zweckberger K (2017) Does suboccipital decompression and evacuation of intraparenchymal hematoma improve neurological outcome in patients with spontaneous cerebellar hemorrhage? Clin Neurol Neurosurg avr 155:22–29 Won SY, Hernández-Durán S, Behmanesh B, Bernstock JD, Czabanka M, Dinc N et al (2024) Functional Outcomes in Conservatively vs Surgically Treated Cerebellar Infarcts. JAMA Neurol 1 avr 81(4):384 1Ratcliff JJ, Hall AJ, Porto E, Saville BR, Lewis RJ, Allen JW et al (2023) Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH): Study protocol for a multi-centered two-arm randomized adaptive trial. Front Neurol. 16 mars. ;14:1126958 Pradilla G, Ratcliff JJ, Hall AJ, Saville BR, Allen JW, Paulon G et al (2024) Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage. N Engl J Med. 11 avr. ;390(14):1277–89 SUPPLEMENTAL DIGITAL CONTENT LEGENDS Supplemental Digital Content 1 Supplemental Figure Appendix Fig 1. Distribution of mRS at discharge, 3 months, 6 months and one year, stratified by stroke type (ischemic vs hemorrhagic) Tables Table 1. Patient demographics Legends: Extra ventricular Drainage (EVD), Glasgow Coma Scale (GCS), Intracranial Hypertension (IH), Interquartile Range (IQR) Median mRS at 1 year 3.5 Total (n = 53) Ischemic (n = 23) Hematoma (n = 30) p Male gender (%) 29 (54.7) 16 (69.6) 13 (43.3) 0.094 Age (median [IQR]) 57 [49, 65] 54 [46, 63] 58 [53, 66] 0.212 Cardiovascular risk factor (%) 41 (77) 18 (78) 23 (76.7) 1.000 Admission GCS (med [IQR]) 14 [9, 15] 14 [11, 15] 14 [8, 15] 0.342 Lowest GCS (med [IQR]) 12 [6, 14] 10 [5, 14] 12 [6, 15] 0.467 Clinical signs of IH (%) 12 (22.6) 2 (8.7) 10 (33.3) 0.048 Brainstem compression (%) 26 (49.1) 15 (65.2) 11 (36.7) 0.054 Cranial nerves deficit (%) 14 (26,4) 10 (43.5) 4 (13.3) 0.026 Motor deficit (%) 18 (34,0) 12 (52.2) 6 (20.0) 0.020 Pupilar abnormality (%) 6 (11.3) 4 (17.4) 2 (6.7) 0.385 Cerebellar syndrome (%) 28 (52.8) 16 (69.6) 12 (40.0) 0.052 Clinical deterioration (%) 16 (30.2) 10 (43.5) 6 (20.0) 0.079 Total volume (median [IQR]) 41.5 [13.5, 72.5] 51.5 [6.25, 76.5] 41 [22.25, 64.25] 0.804 Lesion (median [IQR]) 22 [8.75, 44.25] 40.5 [2.5, 69.5] 20.5 [12.5, 32] 0.384 Oedema (median [IQR]) 6.5 [2, 22] 2 [0, 8] 15 [5, 33.5] 0.002 Radiologic brainstem compression (%) 34 (64.2) 13 (56.5) 21 (70) 0.391 Tonsillar herniation (%) 15 (28.3) 4 (17.4) 11 (36.7) 0.140 4 th ventricle compression (%) 30 (56.6) 12 (52.2) 18 (60) 0.590 Basal cistern compression (%) 15 (28.3) 6 (26.1) 9 (30) 1.000 Hydrocephalus (%) 33 (62.3) 10 (43.5) 23 (76.7) 0.022 Craniectomy (%) 26 (49.1) 10 (43.5) 16 (53.3) 0.583 EVD (%) 26 (49.1) 8 (34.8) 18 (60) 0.098 ICU mortality 12 (22.6) 4 (17.4) 8 (26.7) 0.610 mRS < 3 at 1 year 22 ( 41.5) 11 ( 47.8) 11 ( 36.7) 0.574 mRS at 1 year (median [IQR]) 3.50 [1.00, 6.00] 2.50 [2.00, 5.00] 4.00 [1.00, 6.00] 0.493 Table 2. Factors associated with Suboccipital Decompressive Craniectomy (SDC) (univariate) Legends : Glasgow Coma Scale (GCS), Interquartile Range (IQR), Suboccipital Decompressive Craniectomy (SDC) SDC (n = 26) No SDC (n = 27) p Age (median [IQR]) 58 [50, 62] 56 [48, 71] 0.722 Lowest GCS 15cm 3 22 (84.6) 12 (46.2) 0.008 Radiologic brainstem compression (%) 23 (88.5) 11 (40.7) 15cm 3 14.55 1.47-404.58 0.047 Hydrocephalus 0.61 0.08-3.66 0.604 Radiologic brainstem compression (%) 9.40 1.65-76.16 0.019 Worst GCS < 13 6.07 1.37-35.02 0.025 Table 4. Outcome depending on treatment Legends : Intensive Care Unit (ICU), Suboccipital Decompressive Craniectomy (SDC), Withdrawal of Life Sustaining Therapy (WLST) Total (n = 53) SDC (n = 26) No SDC (n = 27) ICU mortality (%) 12 (22.6) 5 (19.2) 7 (25.9) Brain death (%) 4 (7.5) 2 (7.7) 2 (7.4) WLST (%) 8 (15.1) 3 (11.5) 5 (18.5) Mortality < 1 year (%) 17 (32.1) 8 (30.8) 9 (33.4) Table 5. Factors with associated long term good functional outcome mRS £2 (univariate) Legends : ExtraVentricular Drainage (EVD), Glasgow Coma Scale (GCS), InterQuartile Range (IQR), modified Rankin Scale (mRS), Suboccipital Decompressive Craniectomy (SDC) Bad outcome (n = 31) Good outcome (n = 22) p Age (median [IQR]) 61 [54, 68] 51 [40, 58] 0.002 Admission GCS < 13 (%) 17 (54.8) 2 (9.1) < 0.001 Brainstem compression (%) 20 (64.5) 6 (27.3) 0.012 Total volume (median [IQR]) 48.50[15.75, 76.75] 38 [11.25, 62.25] 0.559 Radiologic brainstem compression (%) 18 (58.1) 16 (72.7) 0.385 Hemorrhagic stroke (%) 19 (61.2) 11 (50) 0.574 Hydrocephalus (%) 21 (67.7) 12 (54.5) 0.395 SDC (%) 15 (48.4) 11 (50) 1.000 EVD (%) 18 (58.1) 8 (36.4) 0.166 Table 6. Factors associated with long term bad functional outcome (mRS > 2 ) (multivariate) Legends : Glasgow Coma Scale (GCS) OR IC 95% p Age > 50 years old 8.25 1.32-84.55 0.039 Admission GCS < 13 27.01 2.94-1137.15 0.019 Clinical brainstem compression 9.81 1.61-102-66 0.027 Total volume 1.00 0.97-1.04 0.987 Hemorrhagic stroke 3.70 0.54-36.76 0.210 Additional Declarations No competing interests reported. Supplementary Files AppendixFigure1.tif Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7573210","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":528815700,"identity":"776a9613-5e0a-4925-86a9-18845f1271ab","order_by":0,"name":"Salomé Smadja","email":"","orcid":"","institution":"Hôpital Lariboisière","correspondingAuthor":false,"prefix":"","firstName":"Salomé","middleName":"","lastName":"Smadja","suffix":""},{"id":528815701,"identity":"8eea64aa-c9fb-4bab-9cc0-4a6b517783db","order_by":1,"name":"Samuel Gaugain","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIiWNgGAWjYNCCAiidwGDDwCABZFQQ1GIA15IG0XKGaC0MDIcJa5FvP50m8cGAwa5/RvrFDw93nJc3l+49wHBwDx7zz+Ruk5xhwJA840ZOsUTimduGO+ecS2A48Ayfk3K3SfMAtTDcyEmQSGy7zbjhRo4B84cDeBzW/3ab9B+gFvkbOck/EtvO2YO0MBzAo4XhBtAWoF12BjfSjwFtOZBIUIvBjbebLXsMJBIMz7xhs0hsS07eOSMv4QA+LfL9uRtv/KiwsZc7nv745s82O9vtErkHH+B1GARIJDYw8EBix4CBh4GwBiCwZ2BgfwDXMgpGwSgYBaMAGQAA3OVbs6wLArcAAAAASUVORK5CYII=","orcid":"","institution":"Hôpital Lariboisière","correspondingAuthor":true,"prefix":"","firstName":"Samuel","middleName":"","lastName":"Gaugain","suffix":""},{"id":528815702,"identity":"c8e48bc7-8c08-4a54-8e2f-7fe175181d04","order_by":2,"name":"Romain Barthélemy","email":"","orcid":"","institution":"Hôpital Lariboisière","correspondingAuthor":false,"prefix":"","firstName":"Romain","middleName":"","lastName":"Barthélemy","suffix":""},{"id":528815703,"identity":"b37a759e-0919-48d9-9b6f-75dacb24dac0","order_by":3,"name":"Anne-Laure Bernat","email":"","orcid":"","institution":"Hôpital Lariboisière","correspondingAuthor":false,"prefix":"","firstName":"Anne-Laure","middleName":"","lastName":"Bernat","suffix":""},{"id":528815705,"identity":"52fe23a8-1fa4-4d1a-9b08-8c5d78dc0f30","order_by":4,"name":"Jean-Pierre Guichard","email":"","orcid":"","institution":"Hôpital Lariboisière","correspondingAuthor":false,"prefix":"","firstName":"Jean-Pierre","middleName":"","lastName":"Guichard","suffix":""},{"id":528815707,"identity":"6fda46a9-2e63-49d1-bb05-873150fc0e9d","order_by":5,"name":"Benjamin Huot","email":"","orcid":"","institution":"Hôpital Lariboisière","correspondingAuthor":false,"prefix":"","firstName":"Benjamin","middleName":"","lastName":"Huot","suffix":""},{"id":528815708,"identity":"02b30a64-921a-40a5-a483-b5e9c4bf165a","order_by":6,"name":"Benjamin G. 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1","display":"","copyAsset":false,"role":"figure","size":63412,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of mRS at one year according to procedure\u003c/p\u003e\n\u003cp\u003eLegends: a modified Rankin Scale from 0 to 2 at one year is considered a good outcome.\u003c/p\u003e","description":"","filename":"15.png","url":"https://assets-eu.researchsquare.com/files/rs-7573210/v1/a408e2d9dee50b0ffff4010c.png"},{"id":93890749,"identity":"550e9f60-a583-4ca6-aca1-600d3fc87513","added_by":"auto","created_at":"2025-10-20 00:18:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":63412,"visible":true,"origin":"","legend":"","description":"","filename":"15.png","url":"https://assets-eu.researchsquare.com/files/rs-7573210/v1/d46298a67a4b25acc87287da.png"},{"id":93890692,"identity":"34dd1ec1-c58c-4f99-9aef-a927f1a77711","added_by":"auto","created_at":"2025-10-20 00:11:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":46753,"visible":true,"origin":"","legend":"","description":"","filename":"24.png","url":"https://assets-eu.researchsquare.com/files/rs-7573210/v1/5c65f651ba70cc19e9bb99ed.png"},{"id":93890951,"identity":"d982ee00-8c2b-4d48-a083-a1c32544f898","added_by":"auto","created_at":"2025-10-20 00:35:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1220841,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7573210/v1/d785fc8b-4102-4740-83a0-63fe091553e7.pdf"},{"id":93669447,"identity":"cedc8b77-24a2-49c1-9d9d-2913a71d94e7","added_by":"auto","created_at":"2025-10-16 09:39:24","extension":"tif","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":655480,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixFigure1.tif","url":"https://assets-eu.researchsquare.com/files/rs-7573210/v1/a50440c2cc3169533aaee068.tif"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outcomes of patients with posterior fossa stroke admitted to the ICU: an observational retrospective cohort","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eStrokes occurring in the posterior fossa represent a sub-group among cerebro-vascular events with specific complications, management and outcomes. Cerebellar hematomas account for 10% of all intracranial hemorrhage whereas cerebellar infarcts only 1\u0026ndash;4% of all brain ischemic strokes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). They represent nearly 500 000 patients per year worldwide and some of them will require admission to intensive care units (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Indeed, ICU admitted severe cerebro-vascular accidents are associated with a grim prognosis of 30,9% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) and 9\u0026ndash;39% mortality (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) for cerebellar hematoma and posterior fossa ischemia respectively.\u003c/p\u003e\u003cp\u003ePatients with cerebellar strokes should be monitored closely because of the high risk of deterioration in this context of intracranial space-occupying lesions. Neuroimaging plays here a major role in the management of Intensive Care Unit (ICU) patients care as it allows to target the appropriate medical or surgical therapy. The optimal management of posterior fossa space occupying lesions is debated. Surgical treatment, either suboccipital decompressive craniectomy (SDC) or external ventricular drainage (EVD), has become the recommended care for large cerebellar stroke, hemorrhage or infarcts. Recent guidelines from the American Stroke Association (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) and European Stroke Organization (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) recommend decompression in patients with clinical deterioration, signs of brainstem compression and/or hydrocephalus. However, international recommanations are low evidence based and remain weak as no prospective randomized trial has been pursued.\u003c/p\u003e\u003cp\u003eIn order to better document this issue, we conducted a retrospective study to describe the clinical chacteristics, management and outcome of posterior fosa stroke patients admitted to ICU and identify risk factors associated with outcome and surgical management.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eStudy Design\u003c/p\u003e\n\u003cp\u003eWe conducted a monocentric retrospective study of patients admitted to the surgical ICU of a tertiary care hospital in Paris, France.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthics Approval and Consent to Participate\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board “Comité d’Éthique de la Recherche” (CER) Paris Nord (IRB 00006477, HUPNVS, Paris 7 University, AP-HP). Given the retrospective design of the study, informed consent was obtained whenever possible from patients or, if they were unable to consent, from their next-of-kin, in accordance with French regulations. All participants (or their legally authorized representatives) were informed about the study and could refuse inclusion.\u003c/p\u003e\n\u003cp\u003eHuman Ethics and Consent to Participate declarations\u003c/p\u003e\n\u003cp\u003eThe authors confirm that the study was conducted in accordance with institutional ethical standards and with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003ePatient selection\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe included all adults admitted to Intensive Care Unit (ICU) in Lariboisière Hospital in Paris, from January 2016 to December 2021, for a space-occupying cerebellar stroke. A space occupying lesion (7) was defined as an acute cerebellar ischemic or hemorrhagic stroke, with either a radiological mass effect (compression of the fourth ventricle, compression of the quadrigeminal cistern, dilatation of the inferior horn of the lateral ventricle or downward cerebellar herniation) or a decreased level of consciousness (Glasgow Coma Scale (GCS) \u0026lt; 13).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe excluded patients under 18 years old as well as intracranial space occupying lesions (ICSOL) of tumoral, traumatic or infectious nature. Vascular lesions such as subarachnoid hemorrhage or arterioveinous malformation were not included either.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData collection\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe retrospectively collected epidemiological variables (sex, age, cardiovascular risk factors) as well as the characteristics of the stroke (ischemic or hemorrhagic, volume) from medical files.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical data were analyzed, until 48 hours from onset of symptoms: Glasgow Coma Scale (GCS), cerebellar syndrome (ataxia, vertigo and nausea, nystagmus), clinical signs of intracranial hypertension (nausea and vomiting, headache, blurred vision, confusion), signs of brainstem compression such as cranial nerve deficit, including pupilar abnormalities (anisocoria or mydriasis), motor deficit. If patient was sedated on admission, the last medical exam was used. Clinical deterioration during the first 48 hours of symptoms, defined as the loss of \u0026gt;2 points of GCS, was specified.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNeuroradiological images were analyzed by a senior radiologist (JP.G.). The latest brain imaging available before any eventual surgery was selected: Computed Tomography (CT) Scans for hemorrhage and Magnetic Resonance Imaging (MRI) for ischemic strokes (CT if not available).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVolume of bleed or infarct, as well as the size of the surrounding oedema, were calculated using Carestream software (Rochester, New York, USA) and semi-automatic contouring. For ischemic strokes, the swelling was the difference of volume between FLAIR and diffusion weighted sequences in MRI. For hematomas, it was the hypodensity surrounding spontaneous hyperdensity. According to international recommandations (5), intracranial hemorrhage was considerd to be of large volume if of more than 15cm3.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMass effect of the space-occupying stroke was defined according to the scoring system of Jauss et al (8), composed of 3 separated items: compression of the fourth ventricle, compression of the quadrigeminal cistern and dilatation of the inferior horn of the lateral ventricle. The presence of one or more of those signs, or of downward cerebellar herniation, suggests an increasing pressure in the posterior fossa. Hydrocephalus was analyzed separately, as it is a direct consequence of a fourth ventricle compression or intraventricular hemorrhage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll patients were provided medical care according to international and local protocols. This involved optimizing cerebral perfusion pressure by managing factors such as hypertension, temperature, hyper or hypocapnia, as well as addressing ionic and metabolic imbalances.\u003c/p\u003e\n\u003cp\u003eThe decisions to perform Suboccipital Decompressive Craniectomy (SDC) and Extraventricular Drainage (EVD) insertion were made after a multidisciplinary discussion between neurosurgical and neuro-ICU teams. The SDC was systematically bilateral with ablation of the posterior arch of the atlas. In cases of hemorrhagic lesions treated with SDC, a necrosectomy (partial or total) could be performed as a complementary intervention. Alternatively, for cases not requiring surgical decompression, an EVD could be proposed. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOutcomes\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe outcome assessment was the modified Rankin scale (mRS) score, ranging from 0 to 6. We defined patients with mRS ≤ 2 having a good outcome. This assessment was performed at discharge, at follow up visits and until a year after day of admission. For patients that passed away in ICU, the cause of death (brain death or withdrawal of life sustaining therapies) was specified.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData analysis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults are provided in both absolute values and percentages for categorical variables and in median and interquartile range for continuous variables. In univariable analyses, group comparisons were conducted using Fisher's test for categorical variables and the Wilcoxon test for continuous variables.\u003c/p\u003e\n\u003cp\u003eIn multivariable analyses, factors associated with suboccipital decompressive craniectomy, and prognosis were tested in a binomial logistic regression model. Variables were selected from those with a p-value \u0026lt; 0.05 in univariable analysis. The total volume of the lesion, a commonly known prognostic factor, was integrated into the multivariable analysis.\u003c/p\u003e\n\u003cp\u003eThe mRS at discharge from ICU predicting the one-year prognosis was determined using the Youden method. Confidence intervals were determined through stratified resampling based on the simulation of 2000 samples.\u003c/p\u003e\n\u003cp\u003eStatistical analysis was conducted using R software version 4.3.0 (R Core Team, 2023, R Foundation for Statistical Computing, Vienna, Austria, https://www.R-project.org), and the packages TableOne version 0.13.2 and pROC version 1.18.0. A p-value \u0026lt; 0.05 was considered statistically significant\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e53 patients have been admitted to ICU between 2017 and 2021 with a cerebellar stroke. 26 patients (49%) of them underwent neurosurgery with a suboccipital decompressive craniectomy. Seven (13%) had EVD only.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBaseline Characteristics, Clinical exam, Neuroimaging\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatient demographics are presented in Table 1. 55% (n = 29) of patients were male, with a median age of 57 years old. Most of them have at least one cardiovascular risk factor (77%). Admission median GCS was 14 [IQR 9, 15] and 30% of patients experienced clinical deterioration within 48 hours. The median lowest GCS was at 12 [IQR 6, 14].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e23% (n = 12) of patients presented with signs of intracranial hypertension, sometimes overlapping with cerebellar syndrome, observed in 53% (28). 26 patients (49%) had indirect signs of brainstem compression with 18 (34%) motor deficit and 18 cranial nerve deficit (with 6 pupilar abnormalities).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMedian total volume was 41.5 [IQR 13.5, 72.5] cm2 with 64% (n = 34) of signs of posterior fossa hypertension (either cistern or 4th ventricle compression or tonsillar herniation) and 33 out of 53 (62%) hydrocephalus.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDecompressive Surgery\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOut of 53 critically ill patients, 26 (49%) were treated by SDC and 19 of them received additional EVD.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients that underwent decompressive surgery had more neurological failure with 70% (18/26) of patients with a GCS \u0026lt; 13 against only 34% (9/27) in the other group (Table 2). Moreover, the volume of the stroke (lesion and oedema) was significatively more important in the craniectomy group with a total of 57 cm3 (IQR [35, 82]) against 18 cm3 [7, 65]. Neuroimaging also showed more indirect signs of posterior fossa hypertension (88% in the craniectomy group vs 41%, p \u0026lt; 0.001) and hydrocephalus (81% in the SDC group vs 44% if SDC was not performed, p = 0.01).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn multivariate analysis, independent risk factors associated with decompressive craniectomy were the volume of the lesion, brainstem compression on neuroimaging as well as level of consciousness (Table 3) but not hydrocephalus.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLong-Term Functional Outcome\u003c/p\u003e\n\u003cp\u003eMortality rate in ICU was 23% (n = 12) with 4 brain deaths and 8 linked to a withdrawal of life sustaining therapy (WLST) (Table 4). At 1 year, mortality rate was 32% (17/53).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt one year follow-up, 11/26 (42%) of patients with SDC had a good functional outcome with a mRS score between 0 and 2, against 41% in the medical strategy group (Figure 1). We found no statistical (p = 0.777) difference on functional outcome 1 year after admission between patients that underwent decompressive surgery and those who did not (Table 5). However, patients with bad outcome had worst level of consciousness (55% of admission GCS \u0026lt; 13 vs 9% if good outcome) and more clinical arguments for brainstem compression (64% vs 27%, p = 0.012)\u003c/p\u003e\n\u003cp\u003eIndependent risk factors for bad long-term functional outcome (mRS \u0026gt;2) were older age (after 50 years old), lower level of consciousness at admission, and clinical signs of brainstem compression (Table 6). Neither surgical treatment, volume of lesion nor radiological signs of brainstem compression and hydrocephalus were correlated to outcome. Moreover, there is no difference in long term prognosis between ischemic and hemorrhagic stroke.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEvolution of mRS over time is presented in Figure 2. We observe little change throughout the first year, with only 28% of patients initially dependent at discharge (mRS 3 to 5) that gained a satisfactory level of autonomy (mRS 0-2) during the first year. Furthermore, only 7 out of 42 patients (16.7%) that were discharged from ICU experienced an improvement in functional independence, advancing by more than one mRS category over the course of the year. 76% of these patients remain stable, with an evolution (positive or otherwise) of ≤ 1 Rankin stage. No major differences were observed between ischemic or haemorrhagic strokes (Supp Figure 1 Appendix).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this retrospective study, we found that patients admitted in ICU for cerebellar space occupying strokes had poor one-year prognosis, with around a third of good functional outcome. SDC was not associated with any benefit. Risk factors for poor functional outcome included age, GCS on admission and clinical signs of brainstem compression. SDC were more frequently performed in patients with important stroke volume (more than 15 cm3), radiological signs of brainstem compression and a low level of consciousness within the first 48 hours that had poor long term predicted prognosis. Nonetheless, the role of SDC should be adequately evaluated in further interventional randomized trials.\u003c/p\u003e\n\u003cp\u003ePrevious studies investigated the impact of SDC on patient outcome with discordant results. A prospective study conducted by Jauss (8) found that surgical patients had a lower level of consciousness upon admission, more clinical signs of brainstem compression as well as more radiological mass effet. Hackenberg (9) reaches the same conclusion when he compared the 6 months prognosis of 85 patients with hemorrhagic cerebellar stroke between patients that have been operated on (SDC and/or EVD) and those that were treated medically. Patients that underwent SDC had a lower preoperative GCS and larger hematomas. Nevertheless, no association between surgery and pronosis was found. Using propensity score, they showed that craniectomy was associated with a lower mortality and functional outcome 6 months after surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe differences with our current results could be due to differences in surgery (systematic addition of haematoma evacuation to SDC), types of strokes as we included both ischemic and haemmorhagic lesions, patients characteristics as patient presented here are about 10 years younger than in most studies, and a clinical evaluation at one year instead of 6 month in the study by Hackenberg et al.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMore recently, Won and al (10) conducted a comparison between the one-year prognosis of ischemic cerebellar stroke patients who underwent suboccipital decompressive craniectomy and those who did not. Despite initial differences on both GCS score and infarct volume, they found no statistical difference in long term functional prognosis between these two groups. Interestingly, their study revealed that strokes with a volume exceeding 35mL had a better functional outcome (mRS 0-3) with surgical intervention, while those with a volume of less than 25mL tended to benefit from conservative treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur approach was not limited to the etiology either ischemia or haemorrhage, of the ICSOL, but tried to capture the picture of posterior fossa intracranial hypertension as a whole for which SDC could represent an interesting therapeutic option. Due to anatomical proximity to the brainstem, these lesions are at risk of compressing vital structures, making it a more potent prognostic factor than the neuronal lesion itself. As seen in other types of strokes, the timing and the selection of patients for surgery is crucial and difficult to determine. With recent successes in adeaquately selected patients, minimally invasive surgery appears to be a promising therapeutic (11) in the management of these strokes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRecent guidelines for haemorragic strokes recommend to perform craniotomy if patient degrades clinically, in case of brainstem compression or if the volume of the hematoma is over 15 mL. SDC are not evoked in the guidelines while it may have some advantages with reduction of posterior fossa intracranial hypertension without entering brain tissue. The proper contribution of SDC and hematoma evacuation, alone or combined, remain to be evaluated. In ischemic stroke of the posterior fossa, expert stated that SDC could be performed in patient with brainstem compression but this recommendation was poorly evidenced.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study suffers several limitations. First, the retrospective design of the study likely causes a selection bias of patients, both in ICU admission and surgical indication. Those who did not undergo SDC were less severe or were already limited for surgery due to catastrophic stroke prognosis. Second, as discussed previously, we included patients with both hemorrhagic and ischemic strokes, that have different underlying pathophysiology, clinical presentation and treatment. However, the notion of Intra-Cranial Space Occupying Lesion allows grouping these two diseases, both of which, in the acute phase of intensive care, share a short-term prognosis linked to this increased pressure in the posterior fossa. Third, the study could be underpowered due an insufficient number of patients. Fourth, few studies investigated functional outcome at one year, making the comparisons between studies difficult, but having a good grasp on patient overall status with our 12-month evaluation. Fifth, the monocentric design limits the generalization of our results. Last, new mini-invasive interventions such as necrosectomy are currently under investigation and could represent a new alternative to SDC (12).\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eTo conclude, In the present study, we found that patient admitted in ICU for posterior fossa vascular space occupying lesions had a poor one-year functional outcome with no benefit observed with SDC. SDC should be adequately evaluated in further interventional randomized trials.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCSF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCerebro Spinal Fluid\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputed Tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEVD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eExtra-Ventricular Drainage\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGCS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGlasgow Coma Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eICSOL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntra-Cranial Space Occupying Lesion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntensive Care Unit\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003emRS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003emodified Rankin Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSDC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSub-Occipital Decompressive Craniectomy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWLST\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWithdrawal of Life Sustaining Therapy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e :\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosures\u0026nbsp;:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVenti M. Cerebellar Infarcts and Hemorrhages. In: Paciaroni M, Agnelli G, Caso V, Bogousslavsky J, \u0026eacute;diteurs. Frontiers of Neurology and Neuroscience [Internet]. S., Karger AG (2012) [cit\u0026eacute; 11 d\u0026eacute;c 2022]. pp. 171\u0026ndash;5. Disponible sur: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.karger.com/Article/FullText/333635\u003c/span\u003e\u003cspan address=\"https://www.karger.com/Article/FullText/333635\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDiringer MN, Edwards DF (2001) Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. 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J Clin Diagn Res [Internet]. 2016 [cit\u0026eacute; 26 nov 2023]; Disponible sur: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://jcdr.net/article_fulltext.asp?issn=0973-709x\u0026amp;year=2016\u0026amp;volume=10\u0026amp;issue=8\u0026amp;page=EC01\u0026amp;issn=0973-709x\u0026amp;id=8237\u003c/span\u003e\u003cspan address=\"http://jcdr.net/article_fulltext.asp?issn=0973-709x\u0026amp;year=2016\u0026amp;volume=10\u0026amp;issue=8\u0026amp;page=EC01\u0026amp;issn=0973-709x\u0026amp;id=8237\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJauss M, Krieger D, Hornig C, Schramm J, Busse O (1999) Surgical and medical management of patients with massive cerebellar infarctions: results of the German-Austrian Cerebellar Infarction Study. J Neurol 29 avr 246(4):257\u0026ndash;264\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHackenberg KAM, Unterberg AW, Jung CS, B\u0026ouml;sel J, Sch\u0026ouml;nenberger S, Zweckberger K (2017) Does suboccipital decompression and evacuation of intraparenchymal hematoma improve neurological outcome in patients with spontaneous cerebellar hemorrhage? Clin Neurol Neurosurg avr 155:22\u0026ndash;29\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWon SY, Hern\u0026aacute;ndez-Dur\u0026aacute;n S, Behmanesh B, Bernstock JD, Czabanka M, Dinc N et al (2024) Functional Outcomes in Conservatively vs Surgically Treated Cerebellar Infarcts. JAMA Neurol 1 avr 81(4):384\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e1Ratcliff JJ, Hall AJ, Porto E, Saville BR, Lewis RJ, Allen JW et al (2023) Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH): Study protocol for a multi-centered two-arm randomized adaptive trial. Front Neurol. 16 mars. ;14:1126958\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePradilla G, Ratcliff JJ, Hall AJ, Saville BR, Allen JW, Paulon G et al (2024) Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage. N Engl J Med. 11 avr. ;390(14):1277\u0026ndash;89\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSUPPLEMENTAL DIGITAL CONTENT LEGENDS\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSupplemental Digital Content 1 Supplemental Figure\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAppendix Fig 1. Distribution of mRS at discharge, 3 months, 6 months and one year, stratified by stroke type (ischemic vs hemorrhagic)\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cem\u003eTable 1. Patient demographics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLegends: Extra ventricular Drainage (EVD), Glasgow Coma Scale (GCS), Intracranial Hypertension (IH), Interquartile Range (IQR)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eMedian mRS at 1 year 3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 53)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIschemic\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 23)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHematoma\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale gender (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e29 (54.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e16 (69.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e13 (43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.094\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (median [IQR])\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e57 [49, 65]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e54 [46, 63]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e58 [53, 66]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.212\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiovascular risk factor (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e41 (77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e18 (78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e23 (76.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdmission GCS (med [IQR])\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e14 [9, 15]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e14 [11, 15]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e14 [8, 15]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.342\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLowest GCS (med [IQR])\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e12 [6, 14]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e10 [5, 14]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e12 [6, 15]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.467\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical signs of IH (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e12 (22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e10 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.048\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBrainstem compression (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e26 (49.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e15 (65.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e11 (36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eCranial nerves deficit (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e14 (26,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e10 (43.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e4 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eMotor deficit (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e18 (34,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e12 (52.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e6 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003ePupilar abnormality (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e6 (11.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e4 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e2 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.385\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCerebellar syndrome (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;28 (52.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e16 (69.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e12 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical deterioration (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e16 (30.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e10 (43.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e6 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.079\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal volume (median [IQR])\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e41.5 [13.5, 72.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e51.5 [6.25, 76.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e41 [22.25, 64.25]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.804\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eLesion (median [IQR])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e22 [8.75, 44.25]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e40.5 [2.5, 69.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e20.5 [12.5, 32]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.384\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eOedema (median [IQR])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e6.5 [2, 22]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e2 [0, 8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e15 [5, 33.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRadiologic brainstem compression (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e34 (64.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e13 (56.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e21 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.391\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eTonsillar herniation (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e15 (28.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e4 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e11 (36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.140\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e4\u003csup\u003eth\u003c/sup\u003e ventricle compression (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e30 (56.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e12 (52.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e18 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.590\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eBasal cistern compression (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e15 (28.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e6 (26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e9 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHydrocephalus (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e33 (62.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e10 (43.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e23 (76.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCraniectomy (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e26 (49.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e10 (43.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e16 (53.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.583\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEVD (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e26 (49.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e8 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e18 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.098\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eICU mortality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e12 (22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e4 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e8 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.610\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003emRS \u0026lt; 3 at 1 year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e22 ( 41.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e11 ( 47.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e11 ( 36.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.574\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003emRS at 1 year (median [IQR])\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e3.50 [1.00, 6.00]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e2.50 [2.00, 5.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e4.00 [1.00, 6.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.493\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2. Factors associated with Suboccipital Decompressive Craniectomy (SDC) (univariate)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLegends : Glasgow Coma Scale (GCS), Interquartile Range (IQR), Suboccipital Decompressive Craniectomy (SDC)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"621\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSDC\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 26)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo SDC\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 27)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (median [IQR])\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e58 [50, 62]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e56 [48, 71]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.722\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLowest GCS \u0026lt; 13 (med [IQR])\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e18 (69.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e9 (34.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBrainstem compression (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e13 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e13 (48.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal volume (median [IQR])\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e57 [35, 82]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e18 [7, 65]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVolume \u0026gt; 15cm\u003csup\u003e3\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e22 (84.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e12 (46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRadiologic brainstem compression (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e23 (88.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e11 (40.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHydrocephalus (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e21 (80.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e12 (44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eTable 3. Factors associated with Suboccipital Decompressive Craniectomy (SDC) (multivariate)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLegends : Glasgow Coma Scale (GCS)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"589\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIC 95%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVolume \u0026gt; 15cm\u003csup\u003e3\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e14.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1.47-404.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.047\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHydrocephalus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.08-3.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.604\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRadiologic brainstem compression (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e9.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1.65-76.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWorst GCS \u0026lt; 13\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1.37-35.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 4. Outcome depending on treatment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLegends : Intensive Care Unit (ICU), Suboccipital Decompressive Craniectomy (SDC), Withdrawal of Life Sustaining Therapy (WLST)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"621\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 53)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSDC\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 26)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo SDC\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 27)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eICU mortality (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e12 (22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e5 (19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e7 (25.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eBrain death (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e4 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e2 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2 (7.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eWLST (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e8 (15.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e3 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e5 (18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMortality \u0026lt; 1 year (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e17 (32.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e8 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e9 (33.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 5. Factors with associated long term good functional outcome mRS\u0026nbsp;\u003c/em\u003e\u0026pound;2 \u003cem\u003e(univariate)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLegends : ExtraVentricular Drainage (EVD), Glasgow Coma Scale (GCS), InterQuartile Range (IQR), modified Rankin Scale (mRS), Suboccipital Decompressive Craniectomy (SDC)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"621\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBad outcome\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 31)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGood outcome\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 22)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (median [IQR])\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e61 [54, 68]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e51 [40, 58]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdmission GCS \u0026lt; 13 (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e17 (54.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e2 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBrainstem compression (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e20 (64.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e6 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal volume (median [IQR])\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e48.50[15.75, 76.75]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e38 [11.25, 62.25]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.559\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRadiologic brainstem compression (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e18 (58.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e16 (72.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.385\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemorrhagic stroke (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e19 (61.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e11 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.574\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHydrocephalus (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e21 (67.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e12 (54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.395\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSDC (%)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e15 (48.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e11 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEVD (%)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e18 (58.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e8 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.166\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eTable 6. Factors associated with long term bad functional outcome (mRS\u0026nbsp;\u003c/em\u003e\u0026gt; 2\u003cem\u003e) (multivariate)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLegends : Glasgow Coma Scale (GCS)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"473\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIC 95%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge \u0026gt; 50 years old\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e8.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e1.32-84.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdmission GCS \u0026lt; 13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e27.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e2.94-1137.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical brainstem compression\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e9.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e1.61-102-66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal volume\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e0.97-1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e0.987\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemorrhagic stroke\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e3.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e0.54-36.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e0.210\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cerebellar stroke, Haemorrhagic stroke, Intra-Cranial Space Occupying Lesion, Ischemic stroke, Posterior Fossa, Sub-Occipital Decompressive Craniectomy","lastPublishedDoi":"10.21203/rs.3.rs-7573210/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7573210/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground and Objectives:\u003c/h2\u003e\u003cp\u003ePosterior fossa strokes pose specific challenges in terms of management and outcomes. Many patients require intensive care unit (ICU) admission and might require surgical interventions, such as suboccipital decompressive craniectomy (SDC). The objective of this study was to describe the clinical chacteristics, management and outcomes of posterior fosa stroke patients admitted to ICU and to identify risk factors associated with outcomes and surgical management\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis is a retrospective monocentric study of patients that were admitted to a tertiary hospital neuro-ICU for a cerebellar stroke. Clinical characteristics, surgical management and outcome were retrieved from medical files. Good functionnal outcome, defined as a mRS score\u0026thinsp;\u0026lt;\u0026thinsp;2, was assesed at one year.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e53 patients were included. At one year follow-up, 22/53 (41.5%) of patients had a good functional outcome. 26/53 (49%) were treated by SDC and 26/53 (49.1%) had an EVD. ICU mortality was 23%, with a one-year mortality rate of 32%. Factors associated with SDC were volume of the lesion, brainstem compression on neuroimaging and level of consciousness. We found no association between 1-year functional outcome (mRS) and SDC. Younger age (under 50 years old), higher level of consciousness on admission, and absence of signs of brainstem compression were associated with a better outcome.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eWe found that patient admitted in ICU for posterior fossa vascular space occupying lesions had a poor one-year functional outcome with no benefit observed from SDC. SDC should be adequately evaluated in further interventional randomized trials.\u003c/p\u003e","manuscriptTitle":"Outcomes of patients with posterior fossa stroke admitted to the ICU: an observational retrospective cohort","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-16 09:31:19","doi":"10.21203/rs.3.rs-7573210/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e103bc77-54a6-4b56-85fb-09dbf4799365","owner":[],"postedDate":"October 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-16T12:08:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-16 09:31:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7573210","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7573210","identity":"rs-7573210","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}