Background and Purpose Because the timing and strategy of surgical int
ervention in massive cerebellar infarction remains controversial, we r
eport our experience with the management of 52 such patients. Methods
Case records, computed tomographic scans, surgical reports, and angiog
rams of 52 patients with space-occupying cerebellar infarction defined
by computed tomographic criteria were reevaluated with regard to clin
ical course, etiology, therapeutic management, mortality, and function
al outcome. Results In most cases clinical deterioration started on th
e third day after stroke, and a comatose state was reached within 24 h
ours. Sixteen patients were treated medically, and 30 by suboccipital
craniectomy (22 plus ventriculostomy, 12 plus tonsillectomy). Ten pati
ents primarily had ventriculostomy, which in 4 patients was supplement
ed by craniotomy because of continuing deterioration. Twenty-nine pati
ents made a good recovery, 15 remained disabled, and 8 died. Even coma
tose patients had a 38% chance of a good recovery with decompressive s
urgery. Age older than 60 years (P=.0043) and probably initial brain s
tem signs (P=.0816) and a late clinical stage (P=.0893) were linked wi
th a fatal or disabling outcome. Conclusions Decompressive surgery sho
uld be the treatment of choice for massive cerebellar infarction causi
ng progressive brain stem signs or impairment of consciousness.