{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T04:35:35Z","timestamp":1791434135469,"version":"4.3.3"},"reference-count":49,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2023,4,28]],"date-time":"2023-04-28T00:00:00Z","timestamp":1682640000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: There remains uncertainty regarding optimal definitive management for malignant posterior circulation infarcts (MPCI). While guidelines recommend neurosurgery for malignant cerebellar infarcts that are refractory to medical therapy, concerns exist about the functional outcome and quality of life after decompressive surgery. Objective: This study aims to evaluate the outcomes of surgical intervention compared to medical therapy in MPCI. Methods: In this systematic review, MEDLINE, Embase and Cochrane databases were searched from inception until 2 April 2021. Studies were included if they involved posterior circulation strokes treated with neurosurgical intervention and reported mortality and functional outcome data. Data were collected according to PRISMA guidelines. Results: The search yielded 6677 studies, of which 31 studies (comprising 723 patients) were included for analysis. From the included studies, we found that surgical therapy led to significant differences in mortality and functional outcomes in patients with severe disease. Neurological decline and radiological criteria were often used to decide the timing for surgical intervention, as there is currently limited evidence for preventative neurosurgery. There is also limited evidence for the superiority of one surgical modality over another. Conclusion: For patients with MPCI who are clinically stable at the time of presentation, in terms of mortality and functional outcome, surgical therapy appears to be equivocal to medical therapy. Reliable evidence is lacking, and further prospective studies are rendered.<\/jats:p>","DOI":"10.3390\/jcm12093185","type":"journal-article","created":{"date-parts":[[2023,4,28]],"date-time":"2023-04-28T09:54:53Z","timestamp":1682675693000},"page":"3185","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":8,"title":["Functional and Mortality Outcomes with Medical and Surgical Therapy in Malignant Posterior Circulation Infarcts: A Systematic Review"],"prefix":"10.3390","volume":"12","author":[{"given":"Nicole-Ann","family":"Lim","sequence":"first","affiliation":[{"name":"Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hong-Yi","family":"Lin","sequence":"additional","affiliation":[{"name":"Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Choon Han","family":"Tan","sequence":"additional","affiliation":[{"name":"Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 636921, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4338-3876","authenticated-orcid":false,"given":"Andrew F. W.","family":"Ho","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore"},{"name":"Pre-Hospital & Emergency Care Research Centre, Duke-NUS Medical School, Singapore 169547, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tseng Tsai","family":"Yeo","sequence":"additional","affiliation":[{"name":"Division of Neurosurgery, Department of Surgery, National University Health System, Singapore 119074, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5256-5669","authenticated-orcid":false,"given":"Vincent Diong Weng","family":"Nga","sequence":"additional","affiliation":[{"name":"Division of Neurosurgery, Department of Surgery, National University Health System, Singapore 119074, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1824-9077","authenticated-orcid":false,"given":"Benjamin Y. Q.","family":"Tan","sequence":"additional","affiliation":[{"name":"Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore"},{"name":"Division of Neurology, Department of Medicine, National University Health System, Singapore 119074, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6866-9531","authenticated-orcid":false,"given":"Mervyn J. R.","family":"Lim","sequence":"additional","affiliation":[{"name":"Division of Neurosurgery, Department of Surgery, National University Health System, Singapore 119074, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4249-0402","authenticated-orcid":false,"given":"Leonard L. L.","family":"Yeo","sequence":"additional","affiliation":[{"name":"Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore"},{"name":"Division of Neurology, Department of Medicine, National University Health System, Singapore 119074, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,4,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2429","DOI":"10.1056\/NEJMoa1804492","article-title":"Global, Regional, and Country-Specific Lifetime Risks of Stroke, 1990 and 2016","volume":"379","author":"Feigin","year":"2018","journal-title":"N. Engl. J. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1177\/1941874412438902","article-title":"Posterior Circulation Ischemic Stroke\u2014Clinical Characteristics, Risk Factors, and Subtypes in a North Indian Population","volume":"2","author":"Mehndiratta","year":"2012","journal-title":"Neurohospitalist"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1136\/jnnp-2015-311299","article-title":"Posterior Circulation Cerebrovascular Syndromes: Diagnosis and Management","volume":"88","author":"Schulz","year":"2017","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"2728","DOI":"10.1161\/STROKEAHA.118.021785","article-title":"Is Functional Outcome Different in Posterior and Anterior Circulation Stroke?","volume":"49","author":"Sommer","year":"2018","journal-title":"Stroke"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1222","DOI":"10.1161\/01.str.0000441965.15164.d6","article-title":"Recommendations for the Management of Cerebral and Cerebellar Infarction with Swelling: A Statement for Healthcare Professionals from the American Heart Association\/American Stroke Association","volume":"45","author":"Wijdicks","year":"2014","journal-title":"Stroke"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"215","DOI":"10.1016\/S1474-4422(07)70036-4","article-title":"Early Decompressive Surgery in Malignant Infarction of the Middle Cerebral Artery: A Pooled Analysis of Three Randomised Controlled Trials","volume":"6","author":"Vahedi","year":"2007","journal-title":"Lancet Neurol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"326","DOI":"10.1016\/S1474-4422(09)70047-X","article-title":"Others Surgical Decompression for Space-Occupying Cerebral Infarction (the Hemicraniectomy After Middle Cerebral Artery Infarction with Life-Threatening Edema Trial [HAMLET]): A Multicentre, Open, Randomised Trial","volume":"8","author":"Hofmeijer","year":"2009","journal-title":"Lancet Neurol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"775","DOI":"10.3171\/2016.3.JNS1683","article-title":"Is Life Worth Living? Decompressive Craniectomy and the Disability Paradox","volume":"125","author":"Honeybul","year":"2016","journal-title":"J. Neurosurg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1007\/s00701-017-3329-3","article-title":"Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction Including Patients with Additional Involvement of the Anterior And\/or Posterior Cerebral Artery Territory-Outcome Analysis and Definition of Prognostic Factors","volume":"160","author":"Munoz","year":"2018","journal-title":"Acta Neurochir."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e375","DOI":"10.1016\/j.wneu.2019.11.177","article-title":"Posterior Fossa Surgery for Stroke: Differences in Outcomes Between Cerebellar Hemorrhage and Infarcts","volume":"135","author":"Lee","year":"2020","journal-title":"World Neurosurg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"450","DOI":"10.1016\/j.wneu.2017.10.144","article-title":"Suboccipital Decompressive Craniectomy for Cerebellar Infarction: A Systematic Review and Meta-Analysis","volume":"110","author":"Ayling","year":"2018","journal-title":"World Neurosurg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"105906","DOI":"10.1016\/j.ijsu.2021.105906","article-title":"The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews","volume":"88","author":"Page","year":"2021","journal-title":"Int. J. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1111\/j.1600-0404.2010.01404.x","article-title":"Clinical Outcome Following Surgical Treatment for Bilateral Cerebellar Infarction","volume":"123","author":"Tsitsopoulos","year":"2011","journal-title":"Acta Neurol. Scand."},{"key":"ref_14","unstructured":"Wells, G., Shea, B., O\u2019Connell, D., Robertson, J., Peterson, J., Welch, V., Losos, M., and Tugwell, P. (2021, November 11). The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomized Studies in Meta- Analysis. Available online: http:\/\/www3.med.unipmn.it\/dispense_ebm\/2009-2010\/Corso%20Perfezionamento%20EBM_Faggiano\/NOS_oxford.pdf."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Moola, S., Munn, Z., Tufanaru, C., Aromataris, E., Sears, K., Sfetic, R., Currie, M., Lisy, K., Qureshi, R., and Mattis, P. (2019). Chapter 7: Systematic Reviews of Etiology and Risk. JBI Reviewer\u2019s Manual, JBI.","DOI":"10.46658\/JBIRM-17-06"},{"key":"ref_16","first-page":"2127","article-title":"Methodological Quality of Case Series Studies: An Introduction to the JBI Critical Appraisal Tool","volume":"18","author":"Munn","year":"2020","journal-title":"JBI Evid. Synth."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"83","DOI":"10.3171\/jns.1982.57.1.0083","article-title":"Cerebellar Infarction with Obstructive Hydrocephalus","volume":"57","author":"Taneda","year":"1982","journal-title":"J. Neurosurg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1007\/s004150050344","article-title":"Surgical and Medical Management of Patients with Massive Cerebellar Infarctions: Results of the German-Austrian Cerebellar Infarction Study","volume":"246","author":"Jauss","year":"1999","journal-title":"J. Neurol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"372","DOI":"10.1161\/01.STR.25.2.372","article-title":"Space-Occupying Cerebellar Infarction. Clinical Course and Prognosis","volume":"25","author":"Hornig","year":"1994","journal-title":"Stroke"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1136\/jnnp.59.3.287","article-title":"Neurosurgical Management of Cerebellar Haematoma and Infarct","volume":"59","author":"Mathew","year":"1995","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"2062","DOI":"10.1161\/01.STR.31.9.2062","article-title":"Neuroimaging in Deteriorating Patients with Cerebellar Infarcts and Mass Effect","volume":"31","author":"Koh","year":"2000","journal-title":"Stroke"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1061","DOI":"10.1227\/01.NEU.0000088766.34559.3E","article-title":"Management of Acute Cerebellar Infarction: One Institution\u2019s Experience","volume":"53","author":"Raco","year":"2003","journal-title":"Neurosurgery"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"28","DOI":"10.4103\/2152-7806.107906","article-title":"Neurosurgical Management of Massive Cerebellar Infarct Outcome in 53 Patients","volume":"4","author":"Mostofi","year":"2013","journal-title":"Surg. Neurol. Int."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"e160","DOI":"10.1016\/j.wneu.2020.06.156","article-title":"Predicting Surgical Intervention in Cerebellar Stroke: A Quantitative Retrospective Analysis","volume":"142","author":"Taylor","year":"2020","journal-title":"World Neurosurg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"957","DOI":"10.1161\/01.STR.23.7.957","article-title":"Treatment of Cerebellar Infarction by Decompressive Suboccipital Craniectomy","volume":"23","author":"Chen","year":"1992","journal-title":"Stroke"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1016\/0303-8467(92)90113-H","article-title":"Management of Cerebellar Infarction with Associated Occlusive Hydrocephalus","volume":"94","author":"Bertalanffy","year":"1992","journal-title":"Clin. Neurol. Neurosurg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1016\/0168-5597(93)90050-Y","article-title":"Monitoring Therapeutic Efficacy of Decompressive Craniotomy in Space Occupying Cerebellar Infarcts Using Brain-Stem Auditory Evoked Potentials","volume":"88","author":"Krieger","year":"1993","journal-title":"Electroencephalogr. Clin. Neurophysiol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1016\/S0090-3019(00)00163-4","article-title":"Is Decompressive Craniectomy for Acute Cerebral Infarction of Any Benefit?","volume":"53","author":"Koh","year":"2000","journal-title":"Surg. Neurol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"539","DOI":"10.1227\/01.NEU.0000228681.45125.E9","article-title":"Endoscopic Third Ventriculostomy for Occlusive Hydrocephalus Caused by Cerebellar Infarction","volume":"59","author":"Baldauf","year":"2006","journal-title":"Neurosurgery"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"259","DOI":"10.1016\/j.jstrokecerebrovasdis.2007.09.001","article-title":"Controversy of Surgical Treatment for Severe Cerebellar Infarction","volume":"16","author":"Kudo","year":"2007","journal-title":"J. Stroke Cerebrovasc. Dis."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"270","DOI":"10.1055\/s-2007-990293","article-title":"Occlusive Hydrocephalus Associated with Cerebellar Infarction Treated with Endoscopic Third Ventriculostomy: Report of 5 Cases","volume":"50","author":"Yoshimura","year":"2007","journal-title":"Minim. Invasive Neurosurg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"3045","DOI":"10.1161\/STROKEAHA.109.550871","article-title":"Long-Term Outcome after Suboccipital Decompressive Craniectomy for Malignant Cerebellar Infarction","volume":"40","author":"Pfefferkorn","year":"2009","journal-title":"Stroke"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"3060","DOI":"10.1161\/STROKEAHA.109.550913","article-title":"Long-Term Outcome after Surgical Treatment for Space-Occupying Cerebellar Infarction: Experience in 56 Patients","volume":"40","author":"Schweickert","year":"2009","journal-title":"Stroke"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"668","DOI":"10.1179\/174313209X380937","article-title":"Hydrocephalus in Posterior Fossa Lesions: Ventriculostomy and Permanent Shunt Rates by Diagnosis","volume":"31","author":"Mangubat","year":"2009","journal-title":"Neurol. Res."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1055\/s-0030-1251983","article-title":"Endoscopic Third Ventriculostomy in Patients with Secondary Triventricular Hydrocephalus from a Haemorrhage or Ischaemia in the Posterior Cranial Fossa","volume":"53","author":"Vindigni","year":"2010","journal-title":"Minim. Invasive Neurosurg."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"2075","DOI":"10.1007\/s00701-011-1120-4","article-title":"Surgical Treatment of Patients with Unilateral Cerebellar Infarcts: Clinical Outcome and Prognostic Factors","volume":"153","author":"Tsitsopoulos","year":"2011","journal-title":"Acta Neurochir."},{"key":"ref_37","first-page":"105","article-title":"Ventriculosubgaleal Shunt in the Management of Obstructive Hydrocephalus Caused by Cerebellar Infarction","volume":"49","author":"Moussa","year":"2013","journal-title":"Alex. J. Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1017\/S0317167100016565","article-title":"Lesions on DWI and the Outcome in Hyperacute Posterior Circulation Stroke","volume":"41","author":"Lee","year":"2014","journal-title":"Can. J. Neurol. Sci."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"2565","DOI":"10.1161\/STROKEAHA.116.014078","article-title":"Preventive Suboccipital Decompressive Craniectomy for Cerebellar Infarction: A Retrospective-Matched Case-Control Study","volume":"47","author":"Kim","year":"2016","journal-title":"Stroke"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"765","DOI":"10.1016\/j.wneu.2017.06.069","article-title":"Neurologic Outcome After Decompressive Craniectomy: Predictors of Outcome in Different Pathologic Conditions","volume":"105","author":"Goedemans","year":"2017","journal-title":"World Neurosurg."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"e80","DOI":"10.1016\/j.wneu.2018.03.178","article-title":"Strokectomy and Extensive Cerebrospinal Fluid Drainage for the Treatment of Space-Occupying Cerebellar Ischemic Stroke","volume":"115","author":"Tartara","year":"2018","journal-title":"World Neurosurg."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1016\/j.clineuro.2018.11.023","article-title":"Long-Term Functional Outcome after Decompressive Suboccipital Craniectomy for Space-Occupying Cerebellar Infarction","volume":"176","author":"Lindeskog","year":"2019","journal-title":"Clin. Neurol. Neurosurg."},{"key":"ref_43","first-page":"21","article-title":"Evaluation of Clinical Significance of Decompressive Suboccipital Craniectomy on the Prognosis of Cerebellar Infarction","volume":"5","author":"Suyama","year":"2019","journal-title":"Fujita Med. J."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"e723","DOI":"10.1016\/j.wneu.2020.09.067","article-title":"Cerebellar Necrosectomy Instead of Suboccipital Decompression: A Suitable Alternative for Patients with Space-Occupying Cerebellar Infarction","volume":"144","author":"Wolfert","year":"2020","journal-title":"World Neurosurg."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"101223","DOI":"10.1016\/j.inat.2021.101223","article-title":"The Impact of Emergent Suboccipital Craniectomy upon Outcome & Prognosis of Massive Cerebellar Infarction: A Single Institutional Study","volume":"25","author":"Maher","year":"2021","journal-title":"Interdiscip. Neurosurg."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"766","DOI":"10.1161\/01.STR.25.4.766","article-title":"Increase in Extracranial Atherosclerotic Carotid Lesions in Patients with Brain Ischemia in Japan. An Angiographic Study","volume":"25","author":"Nagao","year":"1994","journal-title":"Stroke"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1159\/000209282","article-title":"Investigators of the Registry of the Canadian Stroke Network Risk Factors for Posterior Compared to Anterior Ischemic Stroke: An Observational Study of the Registry of the Canadian Stroke Network","volume":"33","author":"Subramanian","year":"2009","journal-title":"Neuroepidemiology"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"3313","DOI":"10.1161\/STROKEAHA.112.658500","article-title":"Risk Factors and Stroke Mechanisms in Atherosclerotic Stroke: Intracranial Compared with Extracranial and Anterior Compared with Posterior Circulation Disease","volume":"43","author":"Kim","year":"2012","journal-title":"Stroke"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"XC","DOI":"10.1177\/23969873211014112","article-title":"European Stroke Organisation (ESO) Guidelines on the Management of Space-Occupying Brain Infarction","volume":"6","author":"Hofmeijer","year":"2021","journal-title":"Eur. Stroke J."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/9\/3185\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T19:25:48Z","timestamp":1760124348000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/9\/3185"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,4,28]]},"references-count":49,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2023,5]]}},"alternative-id":["jcm12093185"],"URL":"https:\/\/doi.org\/10.3390\/jcm12093185","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,4,28]]}}}