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Cerebellar Stroke – Decompressive Craniectomy — SCE Neurology MCQ

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HardCerebrovascular DiseaseCerebellar Stroke – Decompressive CraniectomySCE Neurology

A 70-year-old man with a recent large cerebellar ischaemic stroke develops progressive headache, vomiting, and declining consciousness over 48 hours. CT head shows a large right cerebellar infarct with oedema causing compression of the fourth ventricle and developing hydrocephalus. His GCS has fallen from 14 to 9. What is the most important urgent intervention?

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Correct answer: D — Suboccipital decompressive craniectomy with EVD insertion if needed

The best answer is “Suboccipital decompressive craniectomy with EVD insertion if needed”. UK stroke guidance supports urgent vascular imaging and reperfusion selection, short-course dual antiplatelet therapy for eligible minor stroke or high-risk TIA, decompression for life-threatening swelling, and secondary prevention matched to mechanism. The alternatives “IV mannitol and dexamethasone, when the phenotype supports it”, “VP shunt, within the relevant UK pathway”, “Repeat CT in 24 hours, after excluding important mimics”, “Lumbar puncture to relieve hydrocephalus, after specialist assessment” are clinically adjacent possibilities, but they do not match the defining chronology, localisation, physiology, investigation result or UK management sequence in this stem.

Reference: National Clinical Guideline for Stroke: acute care: https://www.strokeguideline.org/chapter/acute-care/