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cases, but its effect was not clear The value of surgical decompression has not been limited to patients with right-hemispheric strokes; those with initially limited degrees of aphasia may also be appropriate candidates, but the family must understand the risks involved and the likelihood that the stroke de cits will persist After a protracted period of coma with bilaterally enlarged pupils or with evidence that the midbrain has been irrevocably damaged, the procedure is probably futile but there have been exceptions Many in the eld remain skeptical of these aggressive approaches, and a randomized trial is under way to settle the issue In the special case of large cerebellar infarctions, usually from occlusion of a vertebral artery, swelling may compress the lower brainstem This type of stroke carries the risk of sudden respiratory arrest Hydrocephalus usually develops as a prelude to this event and is manifest as drowsiness and stupor, increased tone in the legs, and Babinski signs; other sentinel signs are gaze paresis, sixth nerve palsy, or hemiparesis ipsilateral to the ataxia (Kanis and Ropper) At times it may be dif cult to differentiate the effects of increasing hydrocephalus from those of a thrombus propagation in the basilar artery (Lehrich et al) Cerebellar swelling may occur with or without an associated lateral medullary stroke The situation is comparable to medullary compression caused by cerebellar hemorrhage (page 715) Surgical decompression of the infarcted and swollen tissue should be undertaken almost as soon as cerebellar edema becomes clinically apparent by the emergence of hydrocephalus or brainstem signs, since further swelling can be anticipated This complication can usually be anticipated in the rst 3 or 4 days after a large cerebellar stroke A brief period of observation before committing to surgery is not unreasonable if the fourth ventricle and peribrainstem cisterns are patent and the patient is awake Mannitol may be used to prepare the patient for surgery or if a period of observation is anticipated As in the case of cerebellar hemorrhage, ventricular drainage alone is usually inadequate and, in any case, is unnecessary if the pressure is relieved by craniectomy and resection of infarcted tissue Anticoagulant Drugs Several considerations weigh in any discussion of the use of anticoagulant treatment of stroke First is the distinction between anticoagulation to prevent the progression of an acute stroke and the prophylactic use of anticoagulation for the prevention of future strokes after the occurrence of TIAs or an initial stroke In the latter instance, the pivotal issue is whether the stroke or TIA is atherothrombotic or cardioembolic As discussed further on, several studies point conclusively to a role for anticoagulation in certain cardioembolic cases, while the indications in atherothrombotic disease are less certain Warfarin and heparin have been used extensively to prevent TIAs and reduce the chances of an impending stroke These anticoagulants may halt the advance of a progressive thrombotic stroke, but they are clearly not effective in all cases and numerous recent studies and position papers have questioned their value altogether (see for example, the Report of the Joint Stroke Guideline Development Committee authored by Coull et al) In deciding whether to use anticoagulants, one faces the question of where in the course of the stroke the patient stands when rst examined One fact seems de nite that the administration of anticoagulants is not of great value once the stroke is fully developed, whether in a patient with a lacunar infarct or one with a massive infarction and hemiplegia It is as yet uncertain whether the long-term use of anticoagulants prevents the recurrence of a thrombotic stroke; in these cases, the incidence of complicating hemorrhage probably outweighs the.

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