Concomitant or subsequent decompressive craniectomy may or may not be necessary on the basis of factors such as the size of the infarction, neurological condition, degree of brainstem compression, and effectiveness of medical management. I C-LD Recommendation revised from 2014 Brain Swelling. Ventriculostomy is a well-recognized effective treatment for the management of acute obstructive hydrocephalus and is often effective in isolation in relieving symptoms, even among patients with acute cerebellar infarction.289,296 Thus, in patients who develop symptoms of obstructive hydrocephalus from cerebellar infarction, emergency ventriculostomy is a reasonable first step in the surgical management paradigm. If cerebrospinal fluid diversion by ventriculostomy fails to improve neurological function, decompressive suboccipital craniectomy should be performed.289,296,297 Although a risk of upward herniation exists with ventriculostomy alone, it can be minimized with conservative cerebrospinal fluid drainage or subsequent decompression if the cerebellar infarction causes significant swelling and mass effect.289,296 See Table LXIX in online Data Supplement 1. Decompressive suboccipital craniectomy with dural expansion should be performed in patients with cerebellar infarction causing neurological deterioration from brainstem compression despite maximal medical therapy. When deemed safe and indicated, obstructive hydrocephalus should be treated concurrently with ventriculostomy. I B-NR Recommendation revised from 2014 Brain Swelling. The data support decompressive cerebellar craniectomy for the management of acute ischemic cerebellar stroke with mass effect.289,296,297 This surgery is indicated as a therapeutic intervention in cases of neurological deterioration caused by swelling as a result of cerebellar infarction that cannot be otherwise managed with medical therapy or ventriculostomy in the setting of obstructive hydrocephalus.289,296 See Table LXIX in online Data Supplement 1. 5.1.2. Medical Management (Continued) COR LOE New, Revised, or Unchanged When considering decompressive suboccipital craniectomy for cerebellar infarction, it may be reasonable to inform family members that the outcome after cerebellar infarct can be good after the surgery. 