Stroke in the cerebellum: infarction and haemorrhage – Knowledge

1. What this article covers

A stroke in the cerebellum comes in two forms. In the first, a blood vessel closes, part of the cerebellum receives no more blood, and the tissue there dies. That is cerebellar infarction. In the second, a blood vessel bursts and blood collects in the cerebellar tissue. That is cerebellar haemorrhage.

This text covers both forms. The reason lies in what comes afterwards: which movements fail depends on the site within the cerebellum. Whether a vessel closed or burst there makes little difference to that. Balance, walking and accuracy are practised in the same way after both forms, and everyday life raises the same questions. What differs are the causes, the first hours and days in hospital, and the prevention that follows.

This text describes what the cerebellum does, which deficits follow from which site within it, how infarction and haemorrhage differ, what happens during the first days in hospital, what physiotherapy does, how the course unfolds over weeks and months, and what matters in everyday life.

If you know which of the two forms applies to you, the overview in section 3.4 is the place to start. It sets both forms side by side and points to the sections that apply to you.

The text is written for people affected and for their relatives. Technical words appear because you will meet them in medical reports. Each one is explained on first use. After that the everyday word is used. The numbers in square brackets refer to the reference list at the end.

The text does not replace an examination. What applies in your case and what needs doing is determined by a neurologist. What is decided there takes precedence over this text.

2. What the cerebellum does

2.1 Where the cerebellum sits

The cerebellum sits low at the back of the head, beneath the cerebrum and behind the brainstem. The brainstem is the part of the brain that continues into the spinal cord. Breathing, circulation, swallowing and the nerves for the eyes and the face run through it.

The cerebellum weighs about 130 to 150 grams. That is around 10 out of 100 parts of the weight of the brain. It contains more nerve cells than the whole of the rest of the brain together [4].

The cerebellum lies in a bony chamber, the posterior cranial fossa. This chamber is narrow. Its narrowness plays a large part during the first hours and days after a stroke in the cerebellum, and more so after a haemorrhage than after an infarction. Section 7 describes that in detail.

2.2 Three areas of work

The cerebellum works as a matching station. It continuously receives copies of the movement commands from the cerebrum and, at the same time, feedback from muscles, joints, eyes and the balance organ. Out of the comparison of both streams comes a correction. This correction makes movement accurate, smooth and timed to the right moment [3]. The command for the movement itself arises in the cerebrum.

By its layout the cerebellum can be divided into three areas. Each has different tasks:

• The area for balance and eye movement. It lies right at the bottom of the cerebellum and is called the vestibulocerebellum in technical texts. It holds the trunk upright in standing and sitting and keeps the visual image steady when you move your head.
• The area for posture and walking. It lies in the middle, along the structure called the vermis, and is called the spinocerebellum. It regulates steadiness in standing, the sequence of steps and the posture of the trunk.
• The area for target movements and speech. It lies laterally in the two cerebellar halves and is called the cerebrocerebellum. It tunes the movements of arm, hand and the muscles for speaking.

The posterior lateral parts of the cerebellum are additionally connected to areas of the cerebral cortex responsible for language, attention, planning and the regulation of emotion [4]. Damage there therefore also changes thinking and mood. Section 5.10 describes that.

2.3 Why the deficits are on the same body side

After a stroke in the cerebrum the weakness lies on the opposite side. With the cerebellum it is the other way round: damage in the left half of the cerebellum makes the movements of the left arm and the left leg inaccurate [3]. What is meant are the disorders of coordination. If the brainstem is affected as well, signs can be added that follow other rules – section 4.2 describes this. This holds for infarction and haemorrhage alike, because it follows from the wiring rather than from the cause.

The reason lies in the course of the pathways. The connection from the cerebellum to the cerebrum crosses sides once. The connection from the cerebrum to the spinal cord crosses a second time. Two crossings cancel each other out. That is why one half of the cerebellum acts on the same side of the body.

This point has a practical use. If your medical report says the infarction or the haemorrhage is on the right and you also notice an unsteady right hand, you have a set of findings that fit together.

3. Two routes, one place

A stroke in the cerebellum arises by one of two routes. Either a blood vessel closes, or a blood vessel bursts. Both times cerebellar tissue fails, and both times a shortage of space arises in a narrow bony chamber. The sequence in time and the treatment during the first hours differ.

3.1 A closed vessel: the infarction

The cerebellum is supplied by three pairs of arteries. These arteries arise from the two vertebral arteries and from the basilar artery. The vertebral arteries run upwards through openings in the neck vertebrae. At the junction with the head they join to form the basilar artery [7].

If one of these arteries closes, the tissue behind it receives no more blood. Within minutes its function stops. Within hours the tissue dies. The dead area is called an infarction.

The closure usually arises in one of two ways. Either a clot from the heart or from a larger artery is washed in. Or the artery is narrowed on the spot and closes there [1][2]. Section 8 describes the causes one by one.

3.2 A burst vessel: the haemorrhage

In the second form a small vessel bursts in the middle of the cerebellar tissue. Blood escapes and collects between the nerve cells. This collection is called a haematoma. The whole event is called cerebellar haemorrhage [47].

The escaped blood acts in two ways. It destroys the tissue it enters. And it takes up space, because it lies in the narrow chamber in addition to the tissue already there. With an infarction the shortage of space builds over days, as the dead tissue swells. With a haemorrhage it is there from the first minute [49].

A haemorrhage can still grow during the first hours. In a study of 103 people with a brain haemorrhage, the bleed had grown markedly within the first hour after admission in 26 out of 100. In a further 12 out of 100 this happened between the first and the twentieth hour [53]. That study covered brain haemorrhages at all sites and not only in the cerebellum.

The most frequent cause is blood pressure that has been raised over years. Section 9 describes the causes one by one.

3.3 How common both are

Of all strokes worldwide, around 65 out of 100 are infarctions, around 29 out of 100 are haemorrhages within the brain tissue, and around 6 out of 100 are haemorrhages between the coverings of the brain [66]. In Europe and North America the share of haemorrhages is smaller than in Asia.

Cerebellar infarctions are rare. In a Japanese study across 36 hospitals over five years, around 2 out of 100 people with a brain infarction had a cerebellar infarction [5]. Review articles give proportions of the same order [1][2].

Cerebellar haemorrhage is rare as well. In an analysis of four studies covering 6,580 people with a brain haemorrhage, the bleed lay in the cerebellum in 578. That is around 9 out of 100 [50].

The average age is similar for both forms to that of other strokes. The risk factors for the infarction are the usual ones: high blood pressure, atrial fibrillation, diabetes, smoking, raised blood lipids [5]. For the haemorrhage, blood pressure stands further forward [48].

In younger adults each form has causes of its own: for the infarction a tear in the wall of an artery in the neck [19], for the haemorrhage a malformation of the vessels [48]. Section 8.3 and section 9.3 describe them.

3.4 What is the same and what differs

This overview sums up what the following sections set out in full.

What follows from section 11 on applies to both forms. Sections 4 to 10 separate them where they differ, and say in each case which form a statement applies to.

4. Three arteries, three pictures in infarction

Which symptoms appear depends on which of the three arteries is affected. Each supplies a different part of the cerebellum and, along with it, a different part of the brainstem [7].

In the Japanese study of 293 people with cerebellar infarction, the infarction lay in the territory of the superior cerebellar artery in around 52 out of 100, in the territory of the posterior inferior cerebellar artery in around 49 out of 100, and in the territory of the anterior inferior cerebellar artery in around 20 out of 100 [5]. The sum exceeds 100 because one infarction can cover several territories at once.

4.1 The posterior inferior cerebellar artery

In reports this artery is called PICA, after its Latin name arteria cerebelli posterior inferior. It arises from the vertebral artery and supplies the underside of the cerebellum. One branch additionally supplies the lateral extension of the spinal cord within the brainstem.

Typical for an infarction in this territory is a combination of three symptoms: spinning dizziness, headache at the back of the head, and unsteadiness in walking. In a study of 66 people with cerebellar infarction this trio stood in the foreground among the 36 people with a PICA infarction [8].

This artery has a feature the other two do not: if the infarction reaches through it into the brainstem, a picture of its own arises, called Wallenberg syndrome [2]. For physiotherapy it is the most consequential picture in this article. The next section describes it.

4.2 When the infarction reaches the brainstem: Wallenberg syndrome

The posterior inferior cerebellar artery, and the vertebral artery it arises from, give small branches to the lateral edge of the medulla oblongata. This is the lowest part of the brainstem, where it passes into the spinal cord. If that strip is lost as well, signs coming from the brainstem are added to the cerebellar disorder. The combination is called Wallenberg syndrome, or lateral medullary syndrome [2].

Within that strip, pathways and nuclei with quite different tasks lie close together. Each sign can therefore be traced to a structure:

• Sensation in the face, on the side of the infarction. Pain and temperature are perceived less well on that half of the face.
• Sensation in trunk and limbs, on the opposite side. Again pain and temperature. Touch and position sense are preserved, because they travel along a different pathway.
• Swallowing and voice. The soft palate hangs lower on one side, the voice becomes hoarse, swallowing becomes unsafe.
• Eye and lid, on the side of the infarction. The pupil is narrower, the upper lid droops, that half of the face sweats less. This trio is called Horner's syndrome.
• Balance. Spinning dizziness, jerking eye movements, and a pull towards the side of the infarction.
• Aimed movements, on the side of the infarction. Arm and leg become inaccurate, as in a cerebellar infarction without brainstem involvement.
• Hiccups. Persistent hiccups over hours to days occur and are characteristic of this picture.

In a series of 33 people with this picture, Horner's syndrome was found in 30, inaccurate movement on the side of the infarction in 28, and reduced pain perception on the opposite side likewise in 28. Jerking eye movements were present in 20 out of 33, and difficulty swallowing already at onset in 17 out of 33 [69].

Two points help with recognition. The first is the distribution of the sensory loss: face on one side, body on the other. This crossed pattern hardly occurs elsewhere. The second is the preserved strength. The pathway that carries muscle strength runs further forward in the brainstem and is spared [69].

Within that strip, the exact level matters too. In an analysis of 130 people with an infarction confined to the lateral medulla, those with an infarction placed higher up more often had difficulty swallowing, facial weakness and slurred speech. Those with an infarction placed lower down more often had a marked gait disorder and more often headache [70]. In the same analysis a tear in the vessel wall was found as the cause in 15 out of 100; section 8.3 describes it.

For physiotherapy this picture has three consequences that set it apart from a cerebellar infarction without brainstem involvement:

• Swallowing comes before everything else. As long as it has not been tested, nothing is drunk and nothing is eaten. Section 5.6 and section 12.2 describe this.
• The pull to one side shapes the first exercises. It calls for a vertical reference from outside. Section 5.3 and section 12.3 describe this.
• The skin does not report heat reliably – on the body on the opposite side, on the face on the side of the infarction. Heat applications, hot water and hot-water bottles are dosed there by the thermometer and not by what the person feels.

The course of this picture is often more favourable than the first impression suggests. In many people the swallowing disorder resolves over weeks, and so does the pull to one side [2].

4.3 The anterior inferior cerebellar artery

In reports this artery is called AICA, after arteria cerebelli anterior inferior. It arises from the basilar artery. In most cases the artery that supplies the inner ear branches off from it.

For that reason a sudden loss of hearing is particularly characteristic of an infarction in this territory. In a study of 82 people with an AICA infarction, 80 out of 82 had prolonged spinning dizziness. In 49 out of 82, hearing and balance organ failed together [9].

A sudden one-sided loss of hearing together with spinning dizziness therefore belongs in an immediate medical assessment.

4.4 The superior cerebellar artery

In reports this artery is called SCA, after arteria cerebelli superior. It also arises from the basilar artery and supplies the upper surface of the cerebellum.

What stands in the foreground here is the walking disorder. Spinning dizziness and headache occur less often than with a PICA infarction [8]. Slurred speech and inaccurate target movements of the arm on the side of the infarction are frequent in addition [6].

In the Japanese study, people with an SCA infarction were more often drowsy or dulled during the first days and more often unsteady in walking than people with a PICA infarction [5].

Drowsiness is not a feature of this territory from which the site could be read off. It indicates that a lot of tissue is affected, that the brainstem is suffering as well, or that cerebrospinal fluid is backing up. That is why it appears elsewhere in this article as a warning sign (section 7) and not as a means of recognition.

4.5 The three territories side by side

This allocation holds for the usual case. The vessels are laid out slightly differently in every person, and an infarction does not always keep to territory boundaries [7].

4.6 Where a haemorrhage arises

A haemorrhage does not keep to these three territories. It arises in the small branches that run deep into the cerebellum, most often near the cerebellar nuclei. These nuclei lie deep within a half of the cerebellum and are the starting point of every connection that leaves it [47]. From there the blood spreads into the surrounding tissue.

For the symptoms the same rule holds as with an infarction: the site decides. A haemorrhage in the middle, in the area of the vermis, mainly causes unsteadiness of the trunk and in standing. A haemorrhage laterally in one half of the cerebellum causes inaccurate movements of arm and leg on the same body side.

The position in the middle carries an additional meaning. In an analysis of 72 people with a cerebellar haemorrhage, the condition of 33 deteriorated over the course. A haemorrhage in the area of the vermis and a blocked drainage of cerebrospinal fluid went along with that course [51]. Section 7.3 describes what follows from this for the first hours.

5. The symptoms one by one

The collective term for the movement disorder after cerebellar damage is ataxia. The word comes from Greek and means "without order". What is meant is a movement that falls too far or too short, starts at the wrong moment, or is made up of poorly matched parts. With damage confined to the cerebellum, strength is retained throughout [3]. If the damage reaches into the brainstem, weakness or paralysis can be added, because the pathways for muscle strength run there.

5.1 Dizziness and nausea

Many people with a cerebellar infarction experience spinning dizziness at the start. The surroundings appear to rotate, or the body itself appears to rotate. Nausea and vomiting come with it. Head movements make the symptoms worse [1].

This dizziness persists. It lasts hours to days. It differs in that way from positional vertigo, which appears for seconds on turning the head and then stops.

With a cerebellar haemorrhage the symptoms begin just as suddenly. More often than with an infarction, severe headache and repeated vomiting stand in the foreground, and more often standing is impossible from the outset [47].

5.2 Unsteady in standing and walking

The walking disorder after a cerebellar infarction has a recognisable pattern: a wide step track, irregular step length, swaying to the side, slow pace [26]. Standing with the feet close together increases the sway.

Many people describe it as if the floor were moving with them. Some report a feeling like the one after too much alcohol. This comparison has a factual core: alcohol acts on the same cells in the cerebellum that the infarction affects.

When the trunk itself becomes unsteady, the technical term is truncal ataxia. Those affected tip to the side in free sitting although arms and legs are strong. This form needs the most help during the first days.

5.3 When the body is pulled to one side

Some people are pulled towards one side after a stroke in the cerebellum or at the lateral edge of the brainstem, namely towards the side of the damage. It looks like a push: in sitting the trunk tips that way, in standing the weight travels that way, in walking the path veers that way. The technical term is lateropulsion.

The reason lies in perception. The internal reference for "upright" is shifted. In 36 people with an infarction at the lateral edge of the brainstem, the felt vertical was tilted towards the side of the infarction throughout. In 12 of those 36, those with the strongest pull to one side, head posture and eye position were rotated in the same direction as well [71].

From this follows a particular feature of treatment. Someone who sits crooked while being convinced of sitting straight cannot correct this from within. The vertical has to come from outside. Section 12.3 describes what that looks like.

5.4 Inaccurate movements of arm and leg

When reaching for a glass, the hand passes it and then corrects in small zigzag movements. The closer the target, the stronger the tremor. Technically this is called inaccuracy of aim (dysmetria) and target tremor (intention tremor) [3].

Rapid alternating movements become difficult. Turning the palm up and down becomes slow and uneven. Technically this is called dysdiadochokinesia.

Both signs appear on the side of the infarction.

5.5 Slurred speech

The muscles for speaking are tuned by the cerebellum just as the hand is. If that tuning fails, speech becomes slow, choppy and uneven in loudness. The stress within words shifts. Technically this is called dysarthria [2].

Understanding and finding words remain intact. Those affected know what they want to say. The pronunciation itself becomes imprecise. Treatment is provided by speech and language therapy.

5.6 Swallowing

A swallowing disorder arises above all when the infarction or the haemorrhage reaches the brainstem or presses on it. The technical term is dysphagia. It occurs with damage confined to the cerebellum as well, though: in an analysis of 102 people with an infarction in the cerebellum alone, around 13 out of 100 had a swallowing disorder, mostly a mild one [77].

After a stroke of any kind it is common. A review of 24 studies found, depending on the test used, between 37 and 78 out of 100 people affected with a swallowing disorder. After strokes in the brainstem it persisted longer than after strokes in the cerebrum [72].

It matters because saliva, drinks or food can enter the airways without any coughing. Pneumonia can develop from this. People with a swallowing disorder fall ill with it considerably more often, and more often still those in whom entry into the airways has been demonstrated [72].

In hospital, swallowing is therefore tested after every stroke, before anything is eaten, drunk or taken as a tablet for the first time – regardless of whether the brainstem is involved [16][77]. Treatment is carried out by speech and language therapy. Physiotherapy contributes: upright posture while eating, strength for coughing, mobility of neck and chest, and watching whether the voice sounds wet after drinking.

5.7 What the eyes do

After a cerebellar infarction the eyes often jerk rhythmically, especially on looking to the side. Technically this is called nystagmus. Some people see double. Some report that the surroundings wobble while walking [1].

These signs are diagnostically valuable for the doctor. Section 6.2 describes why.

5.8 When hearing declines

Hearing loss occurs above all with an infarction in the territory of the anterior inferior cerebellar artery, because in most cases the artery to the inner ear branches off from it [9]. With the other two territories hearing is as a rule retained. It cannot be ruled out entirely: in some people the artery to the inner ear arises directly from the basilar artery, and an extensive occlusion in the posterior circulation can affect hearing as well [7].

5.9 Headache

Many people affected have headache at the back of the head or in the neck. It starts suddenly [8]. If headache increases during the days after an infarction, that is a warning sign of swelling. Section 7 describes it.

With a haemorrhage, headache is more frequent and more severe, and it often stands in the foreground from the very beginning [47]. A sudden violent headache at the back of the head, of a kind you do not know, together with vomiting and unsteady walking, is an emergency.

5.10 Thinking and mood

An infarction or a haemorrhage in the posterior lateral parts of the cerebellum can change thinking and mood. This combination was described in 1998 in 20 people with cerebellar disease, infarctions and haemorrhages among them [22]. It carries the name cerebellar cognitive affective syndrome, and after its first describer also Schmahmann syndrome.

Four areas are affected [22][23]:

• Planning and switching. Putting several things in order one after another becomes difficult. Moving from one task to the next takes longer.
• Spatial imagination. Going through a route in the mind or making a sketch becomes harder.
• Language. Words come more slowly. Sentences become shorter.
• Mood and behaviour. Some people become flatter in their emotional state. Others become irritable more quickly or cry more easily.

These changes are often noticed by relatives before the person concerned notices them. In many people they recede over weeks to months [4]. Where they persist, they belong in a neuropsychological assessment.

This section matters for relatives, because such changes are otherwise read as a change of character. They have a cause in the tissue.

6. Why a stroke in the cerebellum is often missed

6.1 Dizziness leads most often to a wrong diagnosis

Spinning dizziness with nausea mostly has a benign cause. There are several of them: an irritation of the balance nerve, positional vertigo, vestibular migraine, Menière's disease, and on top of that medicines and circulatory problems. Which one comes into question depends above all on the pattern over time – whether the dizziness lasts, comes in attacks, or appears only with certain head positions [73]. In the first hours a cerebellar infarction sometimes produces exactly the same picture as an irritation of the balance nerve. So does a small cerebellar haemorrhage.

In a study of 240 people with cerebellar infarction, 25 showed spinning dizziness and unsteadiness alone, without further neurological signs. In 24 of these 25 the infarction lay in the medial branch of the posterior inferior cerebellar artery [10].

A summary of 23 studies with 15,721 people shows how this plays out. Of 100 people who came to an emergency department with a stroke, around 9 were classified as something else at first contact. Among people who came because of dizziness it was around 39 out of 100. Among people with weakness it was around 4 out of 100 [12].

One sign separates the two groups well in practice: someone who is dizzy from an irritated balance nerve can as a rule still stand with help and take a few steps. Anyone who cannot needs immediate assessment [1]. The other way round holds too: this sign is a warning sign and not a proof. A severe irritation of the balance nerve can also make standing impossible, and a small stroke sometimes still allows walking. The American emergency guideline on dizziness puts exactly this test of standing and walking in the foreground when no jerking eye movements can be seen [73].

6.2 What the examination of the eyes shows

There is a bedside examination that gives pointers to whether the cause lies in the brain or in the balance organ. It has three parts and is named after its English initials, HINTS [11]:

1. The head impulse test. The doctor turns your head quickly through a small distance and watches whether your eyes stay on the target.
2. Observation of the eye jerking. You look to the left and to the right. The doctor watches whether the jerking changes direction.
3. The cover test. The doctor covers one eye and then the other and watches for a vertical shift in height.

A fourth part is often added, a test of hearing. Sudden one-sided hearing loss points to a cause in the brain, or in the inner ear along the same route (section 4.3). A harmless irritation of the balance nerve does not account for it [73].

In the study that tested this approach, 101 people with prolonged spinning dizziness and at least one vascular risk factor were examined. 76 of them had a cause within the brain, 69 of those a stroke. The three parts together identified all 76 cases. Of the 25 people with a cause in the balance nerve, 1 was wrongly assigned to the stroke group [11]. These figures come from a small, preselected high-risk group examined by a particularly experienced person.

How well the examination performs in everyday practice depends on precisely that. A summary of five studies with 617 people separates the results by who did the examining. When neurologists examined, around 97 out of 100 causes in the brain were identified and around 95 out of 100 causes in the balance organ were correctly assigned. In the analysis that also included emergency physicians, around 83 out of 100 causes in the brain were identified, and of 100 people with a cause in the balance organ only around 44 were correctly assigned [74]. The authors conclude that HINTS on its own, in non-specialist hands, is not enough to rule out a stroke.

Three limits follow, and this article states them explicitly:

• The examination applies to people with prolonged dizziness, not to short attacks and not to dizziness that appears only with certain head positions.
• It requires visible jerking eye movements. Where these are absent, standing and walking are the more important test [73].
• It requires practice. A normal result from untrained hands is not an all-clear [73][74].

For you as the person affected this means: "the eyes were normal" does not replace the question of whether you can stand and walk. If you cannot, that belongs in the conversation.

6.3 What imaging shows and what it does not

Two methods are used. Computed tomography works with X-rays and is finished within a few minutes. Magnetic resonance imaging, usually called MRI in reports, works with a magnetic field and takes longer.

For the haemorrhage the situation is simple. Fresh blood stands out on computed tomography at once, bright and clearly bounded [54]. That is why an assessment begins with computed tomography where a stroke is suspected. It answers the question that decides the next few hours: haemorrhage or infarction.

For dizziness alone, without other signs of a stroke, this does not hold. There, scanning is not done as a matter of routine, because computed tomography mostly does not show a fresh infarction in the back part of the brain anyway. What happens next is decided by the pattern of the dizziness over time and by the examination; what is then needed is rather magnetic resonance imaging and imaging of the vessels [73].

For the infarction the situation is harder. During the first hours computed tomography often remains normal with an infarction. Magnetic resonance imaging shows it in a particular type of image, the diffusion-weighted sequence. In the same study of 101 people, this image was normal within the first 48 hours in 12 out of 100 people with a stroke [11]. All of these infarctions lay in the back part of the brain and were small.

From this follows a rule that matters for you: a normal image during the first hours does not rule out a stroke. Where the suspicion persists, nothing is left to wait. Monitoring in hospital follows and, depending on the course, imaging of the vessels and a second magnetic resonance scan some days later, because a small infarction is then easier to see [1][73].

A small cerebellar haemorrhage gets missed for a different reason, namely when no imaging is done at all because the dizziness was taken to be harmless. The examination of the eyes in section 6.2 separates a cause in the balance nerve from a cause within the brain. Which of the two forms within the brain is present is shown only by the image.

6.4 How to recognise a stroke in the cerebellum

The well-known rule FAST asks about face, arm and speech. It captures strokes in the cerebellum poorly, because weakness is often absent there.

The extended rule BE-FAST puts two questions in front [13]:

• Balance. Has the person suddenly become unsteady? Can they walk without help?
• Eyes. Do they suddenly see double or blurred, or has part of the visual field dropped out?
• Face. Is one corner of the mouth drooping?
• Arm. Does one arm drift down when both are held out?
• Speech. Is the speech slurred?
• Time. Note the time and call 144.

In the study that tested this extension, 736 people with a stroke were analysed. With the three questions about face, arm and speech, 14 out of 100 would have gone undetected. With the two added questions about balance and eyes it was 4 out of 100 [13].

7. The first days: when space runs short

7.1 Why the posterior cranial fossa is narrow

Dead brain tissue attracts water and increases in volume. In the cerebrum this increase has more room. In the cerebellum it takes place in a bony chamber that also holds the brainstem and through which the cerebrospinal fluid drains [14].

An increase in volume within the cerebellum therefore has two possible consequences. It presses on the brainstem. And it blocks the drainage of cerebrospinal fluid, so that the fluid chambers of the brain widen. This widening is called hydrocephalus.

With a haemorrhage the need for space comes earlier. The escaped blood takes up room itself, from the first moment, and the surrounding tissue swells in addition [47][49]. That is why the narrow chamber counts as the decisive problem of the first hours with a haemorrhage.

In the study of 66 people with cerebellar infarction, 11 of the 36 people with a PICA infarction showed a marked mass effect. In 7 of those 36 a widening of the fluid chambers was added, and 4 of these people died. Among the 30 people with an SCA infarction, a marked mass effect occurred in 2 cases [8].

7.2 With an infarction: day two to day four

The swelling usually reaches its peak on the second to fourth day after the infarction [14]. A person can therefore be well on the first day and clearly worse on the third.

The treating team watches for these signs:

• The person becomes drowsy and harder to wake.
• The headache increases.
• The vomiting increases.
• New brainstem signs appear: double vision, difficulty swallowing, unequal pupils, weakness in arm or leg.

For that reason people with a larger cerebellar infarction are monitored during the first days, even when they are well at first [14].

7.3 With a haemorrhage: the first hours

With a haemorrhage the most dangerous time comes earlier. Two processes coincide.

The bleed grows. In the study of 103 people with a brain haemorrhage, the bleed had grown markedly within the first hour after admission in 26 out of 100, and in a further 12 out of 100 between the first and the twentieth hour. This growth went along with a worsening of the condition [53].

The tissue around the bleed swells. This swelling comes later and behaves much as it does with an infarction.

How often the condition deteriorates is shown by an analysis of 72 people with a cerebellar haemorrhage. In 33 of them alertness declined over the course, new brainstem signs appeared, or both. This happened most readily with a haemorrhage in the area of the vermis and with blocked drainage of cerebrospinal fluid [51].

The warning signs are the same as in section 7.2. They appear earlier. That is why monitoring after a cerebellar haemorrhage is close from the start, and why the computed tomography is repeated after a few hours [48].

7.4 What the treating team then does

If the need for space increases, two procedures are available [14]:

• A drain for the cerebrospinal fluid. A thin tube is placed into a fluid chamber of the brain and drains fluid outwards. This helps against the backing up of the fluid.
• An opening of the skull at the back of the head. A piece of bone is removed so that the swollen tissue gains room. Technically this is called suboccipital decompressive craniectomy. This helps against the crowding itself.

These two are not equivalent options. The drain takes away the backed-up fluid, but it does not take away the pressure that the swollen cerebellum exerts on the brainstem from below. On its own it can even cause the tissue to shift upwards. That is why, where there is pressure on the brainstem, it is combined with the opening of the skull [14].

Which people benefit most, and when the best moment is, remains open. For the cerebellum, the European guideline on space-occupying brain infarction states explicitly that the selection of people for decompression or for drainage of cerebrospinal fluid is uncertain [75]. The decision is therefore made for the individual person, from alertness, imaging and course.

How people fare after such an operation is shown by an analysis from Munich covering 57 people. Within the first six months 16 of 57 died. Among the 52 people followed up over an average of 4.7 years, 21 were living independently at the end, 4 were living with severe disability, and 21 had died. Those who also had an infarction in the brainstem had clearly poorer prospects [15].

These figures come from a single hospital and from the years 1995 to 2006. They describe a group with particularly severe courses, because only those were operated on.

With a cerebellar haemorrhage the same two procedures are available, and a third one alongside them: evacuation of the haematoma. The guideline on brain haemorrhage names four occasions on which immediate evacuation is recommended, with or without a drain for the cerebrospinal fluid: a deterioration in alertness or in the neurological signs, pressure on the brainstem, obstructed drainage of cerebrospinal fluid, and a bleed of more than 15 millilitres [48]. Volume is an occasion in its own right here, not merely a contributing factor. The recommendation targets survival. Whether the operation also improves later independence is not thereby settled. In an older study of 50 people the treatment was guided partly by how far the fourth ventricle was compressed [52]. This chamber lies in front of the cerebellum, and cerebrospinal fluid flows through it. That protocol comes from the time before today's guidelines and does not serve as a general rule: an open fourth ventricle does not prove that nothing is pressing on the brainstem, and drainage of cerebrospinal fluid alone may not suffice for a space-occupying cerebellar haemorrhage. Today the course, the pressure on the brainstem, the drainage of cerebrospinal fluid and the volume are judged together [48].

What evacuation achieves is shown by the largest analysis of the question. From four studies covering 6,580 people with a brain haemorrhage, the 578 with a cerebellar haemorrhage were selected. From those, 152 operated and 152 non-operated people were matched to one another who were similar in age, size of the bleed and prior medication [50]:

• After three months around 78 out of 100 in the operated group were alive, and around 61 out of 100 in the non-operated group.
• After twelve months it was around 72 against around 57 out of 100.
• For independence in everyday life at three months no difference appeared: around 31 out of 100 against around 36 out of 100.

In this analysis evacuation went along with more survivors. The share of people who managed everyday life stayed the same. Both findings belong together when an operation is discussed in hospital.

The same analysis additionally split the results by size. With bleeds below roughly 12 to 15 millilitres, evacuation went along with a less favourable course; with larger ones, with a more favourable one [50]. That split was a search within the data and not a question set in advance. On its own it carries no threshold. It points in the same direction as the guideline, whose threshold lies above 15 millilitres; what counts are the four occasions named above.

These figures do not come from a trial with allocation by lot. Who was operated on was decided by the treating team, and matching for age and size makes up for that only in part. A trial with allocation by lot is still missing today [49].

7.5 How things continue after that

Whoever gets through the first week has the most dangerous time behind them. From that point on it is about rehabilitation. The rest of this text deals with that, and it applies to both forms.

8. Where the infarction comes from

After the acute treatment, the source of the clot is searched for. This search decides which medicines you take afterwards [46].

8.1 The heart

In atrial fibrillation the upper chamber of the heart beats irregularly. Clots form in the process and are washed into the brain with the bloodstream. In the Japanese study of 293 people with cerebellar infarction, a washed-in clot could be demonstrated in at least 24 out of 100. In a further 27 out of 100 this cause remained possible [5].

Atrial fibrillation often runs without symptoms and appears in episodes. The heart rhythm is therefore recorded over a longer period after a stroke [46].

8.2 The vessels

Deposits in the vertebral arteries or in the basilar artery narrow the vessel. Particles come loose from that site, or the vessel closes on the spot [2]. Blood pressure, blood lipids, blood sugar and smoking act on this process.

8.3 A tear in the vessel wall

The wall of an artery consists of several layers. If the inner layer tears, blood enters between the layers. The vessel wall bulges inwards, and a clot forms at the site of the tear. Technically this is called dissection [19].

In people under 45 years of age this tear is one of the most frequent causes of a stroke in the back part of the brain [19]. It occurs spontaneously, after a head movement, after a fall, after an accident or after violent coughing.

Typical are neck or occipital pains that begin hours to days before the other symptoms. Anyone with such new pain who then becomes dizzy needs prompt assessment [19].

8.4 Manual treatments at the neck

A connection between manual treatment of the cervical spine and a tear in the vertebral artery has been discussed for decades. Two works give the state of knowledge.

A Canadian analysis of insurance data from Ontario covered more than 100 million person-years. In this population, 818 strokes in the back part of the brain occurred over nine years. People under 45 with such a stroke had more often received chiropractic treatment during the preceding days than comparison persons. During the same days they had equally more often visited a family practice [21]. The authors explain this by the tear having existed beforehand and having caused the neck pain for which the people sought care.

A scientific statement of the American Heart Association from 2014 reaches the same conclusion: a causal connection could not be demonstrated, a connection in time exists, and a residual risk cannot be excluded. The recommendation is to speak about this possibility before a manual treatment at the neck [20].

In our practice, no rapid manipulation of the cervical spine is carried out where neck pain with dizziness has newly appeared. That combination leads first to medical assessment.

8.5 What the assessment looks for

The search usually includes:

• imaging of the neck vessels and the brain vessels with ultrasound, computed tomography or magnetic resonance imaging,
• a recording of the heart rhythm over several days to weeks,
• an ultrasound examination of the heart,
• blood values for sugar and blood lipids,
• blood pressure measurements over 24 hours.

In some people the cause remains open despite a complete assessment. Prevention then follows the risk factors that are present [46].

9. Where the haemorrhage comes from

After a haemorrhage too, the cause is searched for. This search decides which medicines you take afterwards, and it leads to different answers than with an infarction [48].

9.1 Blood pressure

Blood pressure that has been raised over years is the most frequent cause of a cerebellar haemorrhage [47][48]. The pressure acts on the small vessels that run deep into the tissue. Their wall changes slowly and becomes brittle. At some point one spot gives way.

This connection is the reason why treating blood pressure comes first after a haemorrhage. Section 16.2 describes that.

9.2 Blood-thinning medicines

Medicines that inhibit blood clotting are among the frequent accompanying circumstances of a brain haemorrhage. In the analysis of 578 people with a cerebellar haemorrhage, around 60 out of 100 were taking such a medicine before the bleed [50]. That figure comes from hospitals in the United States and Germany between 2006 and 2015 and describes a group with many severe courses. It cannot be read as a general proportion.

No recommendation to stop such a medicine follows from this. It prevents infarctions, and that effect remains. What does follow is twofold: with a haemorrhage, clotting is restored as quickly as possible [57], and afterwards it is weighed afresh whether and when the medicine is started again.

9.3 Vascular malformations and brittle vessels in old age

In younger people without high blood pressure, a malformation of the vessels is looked for. Two forms occur: a tangle of directly connected arteries and veins, and a cushion of thin-walled cavities, called a cavernoma. Both can be found with imaging of the vessels [48].

In older people a different change comes in. A protein is deposited in the walls of the small brain vessels and makes them brittle. Technically this is called cerebral amyloid angiopathy. It leads mainly to haemorrhages in the outer parts of the cerebrum and is rare in the cerebellum [63]. It is looked for nonetheless, because it raises the risk of a further haemorrhage and thereby bears on the decision about blood-thinning medicines.

9.4 What the assessment looks for

The search usually includes:

• blood pressure measurements over 24 hours and the question of how well blood pressure has been controlled so far,
• the clotting values and the complete list of medicines,
• imaging of the brain vessels, above all in younger people and with an unusual position of the bleed,
• magnetic resonance imaging after some weeks, where amyloid angiopathy or a malformation is being looked for,
• blood sugar and blood lipids, because both count for the further prevention.

In some people the cause remains open despite a complete assessment. Prevention then follows blood pressure and the risk factors that are present [48].

10. Treatment in the acute phase

This section stays short, because these decisions are taken in hospital. The first computed tomography decides which of the two routes is taken.

10.1 With an infarction

Dissolving the clot through a vein. A medicine is given into a vein and dissolves the clot. As a basic rule a window of four and a half hours from the start of symptoms applies [17]. That time window is the reason why the time of onset is recorded as precisely as possible.

The rule has an extension that matters for you. Anyone who already has symptoms on waking does not know the time of onset. For such cases, and for selected people beyond the four and a half hours, the imaging decides: if it shows tissue that can still be saved, the treatment comes into question all the same [17]. An unknown time of onset is therefore no reason to delay the call.

Pulling the clot out with a catheter. A catheter is guided through an artery in the groin up to the blockage and the clot is removed. With a blockage of the basilar artery this approach comes into question [16].

10.2 With a haemorrhage

Lowering the blood pressure. High blood pressure favours further bleeding, so it is lowered during the first hours. In a trial with 2,839 people with a brain haemorrhage, one group was lowered rapidly to an upper value below 140, the other according to the practice usual at the time. After three months, 52 out of 100 in the rapidly treated group had died or were severely limited, against 56 out of 100 in the other group. This difference was not statistically secure. A second analysis of the same data, grading the degree of limitation more finely, spoke for the more rapid lowering [55].

The European guideline of 2025 sums up today's position as follows: whether rapid lowering helps on balance remains uncertain. Out of the experience of the specialists, an early lowering of the upper value below 140 is recommended, for small to moderate haemorrhages, in order to limit further bleeding [58]. The lowering is done smoothly. Large swings are unwanted, and the lowest possible value is not the goal. With very large haemorrhages and before an operation the evidence is thinner, and the treating team decides case by case.

Restoring clotting. Anyone taking a clotting-inhibiting medicine is given an antidote. Which one depends on the medicine. A European guideline sums up the approach [57]. This step is urgent, because the bleed grows during the first hours [53].

Managing several values at once. A trial at 121 hospitals with 7,036 people tested a bundle of four measures: rapid blood pressure lowering, treatment of raised blood sugar, treatment of fever, and restoration of clotting. In the hospitals working to this bundle the course was more favourable, and serious adverse events occurred less often: 16 out of 100 against 20 out of 100 [56].

No dissolving of clots. The medicines from section 10.1 are not an option with a haemorrhage, because they would make the bleeding worse. That is the reason why computed tomography is carried out before any such treatment.

10.3 The stroke unit, for both forms

A stroke unit is a ward with a team from nursing, neurology, physiotherapy, occupational therapy and speech and language therapy. A Cochrane review summarises 29 studies with 5,902 people after a stroke. Of every 100 people treated on such a ward rather than on a general ward, 2 more were alive after one year, 6 more were living at home, and 6 more managed everyday life without help from others [18].

11. Why cerebellar damage is practised differently

From here on everything applies to both forms. What is practised follows the site within the cerebellum and what is missing in everyday life.

11.1 The cerebellum matches movement

When you reach for a cup, your brain predicts where your hand will be in 200 milliseconds. It compares this prediction with the feedback from eyes, skin and joints. If the two differ, a correction signal arises. The cerebellum performs this comparison [24].

If the comparison fails, two things happen. The ongoing movement becomes inaccurate. And adaptation to new conditions becomes slower, because it rests on the same correction signal.

11.2 When learning from errors is impaired

Healthy people adapt quickly to a changed environment. Someone wearing glasses that shift the image sideways reaches correctly again after a few attempts. This form of learning is called error-based learning. It depends on the cerebellum [24].

After cerebellar damage this form stays limited [24]. Other routes remain usable:

• Learning from success and failure. Here only whether a movement worked counts, not by how much it went wrong. In a study of 12 people with a cerebellar disease, learning took place along this route and what was learned was retained fully [76].
• Learning through repetition. A movement carried out often enough becomes more reliable.
• Deliberate strategies. Intending to start further left, or to begin more slowly, bypasses the working out of the error.

Three consequences for the practice session follow from this:

• Few tasks with many repetitions are needed. As things progress, pace, direction and surface are varied, so that what has been practised carries outside as well.
• Feedback from outside is needed. A mirror, a video, a marking on the floor or a sentence from the therapist supplies the information that no longer arrives reliably from inside. Which form works best is open.
• A target that can be hit or missed is needed: a mark on the floor, a taped square, a counted number of steps.

11.3 What remains available for practice

The cerebellum holds reserves. If part of the tissue is preserved, neighbouring areas take over part of the tasks. For this capacity an international expert group proposed the term cerebellar reserve in 2020 [25].

The group states that this reserve is addressed by training, and that the evidence for it comes predominantly from animal experiments and from small studies in people with progressive cerebellar diseases [25]. How large the reserve is in an individual person cannot be measured in advance.

12. Physiotherapy step by step

This section summarises the practice. In full – with assessment, the build-up of the individual exercises, the home programme and the checking of progress – it is in the guide Physiotherapy after a stroke in the cerebellum.

12.1 What the site means for practice

All the building blocks of the following sections exist. Which of them come first and are practised longest is indicated by the site; the decision follows the findings, the risk of falling, what can be tolerated, and the goals. Section 2.2 described the three areas of the cerebellum; here they are again, together with what follows from them for therapy.

This mapping is not derived from anatomy alone. In a study of 90 people with a circumscribed cerebellar lesion, it was tested for every image point in the cerebellum which symptoms go with damage at that place. Unsteadiness in standing and walking was tied to the midline, inaccuracy of arm and leg to the deep-lying nuclei and the adjoining cortical parts, and slurred speech to the parts beside the midline in the upper cerebellum [67].

The last row deserves an explanation. Deep within each half of the cerebellum lie the cerebellar nuclei. Everything the cerebellum passes on to the rest of the brain runs through them. In the same study of 90 people, symptoms after damage involving these nuclei persisted at every age, while damage to the cerebellar cortex was compensated better [67]. This is one of the reasons why the starting point after a haemorrhage is worse on average: a haemorrhage arises preferentially near these nuclei (section 4.6).

These mappings are pointers, not a programme. An infarction or a haemorrhage does not keep to boundaries, and many people have several things at once. What is actually practised follows from the examination and from what you are missing in everyday life.

12.2 The first days

An early start belongs to treatment on the stroke unit. On the dose during the first 24 hours there is a large trial with 2,104 people after a stroke [27].

One group was mobilised frequently and extensively within 24 hours. The other group received the usual care of the stroke unit. After three months, 46 out of 100 people in the group with the high early dose were independent in everyday life. In the group with usual care it was 50 out of 100 [27].

From this follows today's approach: out of bed early, in short units, with breaks. The trial included all types of stroke, infarctions and haemorrhages. It was not analysed for stroke in the cerebellum alone.

After a haemorrhage the same principle holds, with two points added. Blood pressure is followed during the first sitting up and the first standing, because it is kept low with medicines during this period. And where surgery was carried out, the start follows the clearance from neurosurgery [48].

During the first days four things matter: sitting safely, standing safely, making nausea and dizziness bearable, and preventing pneumonia, thrombosis and pressure sores.

One task comes before all others, and it does so regardless of the site. Swallowing is tested before anything is eaten or drunk for the first time [16]. Until that has happened, physiotherapy too offers nothing to drink, and the exercises stay dry. Where the damage reaches the brainstem or presses on it, a swallowing disorder is more frequent and more marked; it can occur with damage in the cerebellum alone as well [77]. Section 5.6 describes why.

12.3 Sitting and standing

With truncal ataxia the treatment starts sitting on the edge of the bed, with support at the side. The build-up follows a fixed order:

1. Sitting with hand support, then without.
2. Sitting and reaching forward with one hand, then to the side.
3. Standing with support on both sides, then with one hand on a rail, then freely.
4. Standing with the feet closer together.
5. Standing while turning the head, moving the gaze, picking up an object.

The step to the next stage follows when the previous one succeeds for about 30 seconds without a balancing step. This threshold comes from practice. There is no tested boundary for it.

With a pull to one side (section 5.3) a task of its own is added. Because the felt vertical is shifted, a visible or palpable vertical from outside is needed: a mirror, a vertical edge in the room, tape on the wall, a plumb line, a hand at the shoulder showing where the middle is. What is practised is straightening up against the pull, first in sitting with feedback, then in standing, then without a mirror. This approach comes from practice and from the reasoning that a shifted internal vertical is replaced by an external one. A study with a comparison group testing this for the pull to one side after a stroke in the brainstem does not exist.

From stroke treatment in general there is a summary of 43 studies in the chronic stage. For the Berg Balance Scale, which runs from 0 to 56 points, 28 of these studies with 985 people could be pooled. The groups with an exercise programme were on average 2.2 points higher than the comparison groups (95% confidence interval 1.3 to 3.2) [40]. Programmes with balance, weight-shifting and gait training performed best. These studies included all types of stroke.

12.4 Walking

In walking, work goes into four points: the step track, the pace, the posture of the trunk, and safety when turning.

These exercises are usual:

• Walking along a line on the floor. The line supplies the feedback about the track from outside.
• Walking with a narrowing track. Two strips of tape on the floor set the width.
• Walking with changes of pace, with stopping on command, with changes of direction.
• Walking while turning the head or carrying something.
• Stairs up and down, with one hand on the rail.

For gait training after stroke there is a guideline that emerged in 2020 from a review of the evidence. It recommends walking training at a high heart rate and with many steps as the most effective component for walking speed and walking distance [39]. The guideline refers to people with stroke in general and assumes that the person is steady enough to walk briskly.

For people with marked ataxia, gait training starts with safeguarding. A harness system, a treadmill with handrails, or two people for guidance are possible.

12.5 Arm and hand

With inaccuracy of aim in the arm, the movement is broken down and rebuilt slowly:

• Reaching for a fixed target, at first with the elbow supported.
• Reaching without support, with the gaze held on the target.
• Everyday movements with a target: pouring water, doing up a button, putting a key in a lock.
• Writing and drawing, because fine tuning and feedback come together there.

With target tremor, many people find it helps to rest the elbow or the forearm on a surface. The swing becomes smaller because one joint fewer moves along.

12.6 Gaze and dizziness

When the image wobbles during walking, the gaze is trained. The exercises are called gaze stabilisation. They come from the treatment of disorders of the balance organ and are also used after damage within the brain [42][43].

A usual basic exercise: you hold a letter at arm's length in front of you, fix your eyes on it and turn your head slowly to the left and right. The letter stays sharp. The duration starts at about 20 seconds and is increased over weeks.

On effectiveness with damage inside the brain there is a retrospective analysis of 48 courses of treatment. The people received an average of five sessions over five months. Balance, walking and dizziness complaints improved between start and discharge. There was no comparison group without treatment, so part of the improvement would have occurred without treatment as well. Among the subgroups, the people with cerebellar damage improved the least [42].

With dizziness one further point applies: head movements are brought back in step by step, at an intensity that follows your reaction. Keeping the head still permanently does not lead out of the symptoms, because the load then never rises again.

12.7 Strength and endurance

The ataxia concerns the tuning of movement. Strength and endurance decline nonetheless, because those affected move less for weeks.

A Cochrane review summarises 75 studies with 3,017 people after a stroke. Endurance training reduced restriction in everyday life, measured at the end of the training period. Mixed training of strength and endurance showed a smaller effect in the same direction. In addition, fitness, walking speed and balance improved. No serious adverse events were reported in any of the studies [41].

Strength training follows the same rules as elsewhere: two to three times a week, six to twelve repetitions, increases over weeks. With ataxia, guided machines or exercises in sitting are preferred, because less balance is needed there. On building strength there is a separate article under strength training.

12.8 Aids and weights

A walking stick widens the base of support. A wheeled walker adds guidance. Both increase safety in everyday life and make longer distances possible.

Some people affected receive weight cuffs at the wrist or a vest with weights. The idea behind it: more mass damps the swing. Little speaks for weights on the arm. In 13 people with a cerebellar ataxia, an individually fitted weight improved simple movements from a single joint and mostly worsened movements across several joints again [78]. For weights on the trunk, the review of postural disorders in ataxia states that they showed an effect in individual small studies and that the evidence for them is thin [28]. There a time-limited trial over two to four weeks is defensible; the decision rests on whether you can do more in everyday life with them.

One observation is useful for the choice. Among 12 people with a circumscribed cerebellar lesion, those with inaccurate leg placement adapted their walking to additional weights on the lower leg less well than those with good balance; in them the deep-lying cerebellar nuclei beside the midline were more often involved [68]. Anyone who becomes less steady with weights rather than steadier has a possible explanation here, and the trial is stopped.

12.9 How much and how often

For the amount of practice, one relationship holds in stroke rehabilitation: more practice time goes together with a better result. An analysis of studies in which one group received more therapy time than the other found an advantage for the group with the longer time. The difference was small to moderate (standardised difference 0.35; 95% confidence interval 0.26 to 0.45) [37].

A summary of 467 studies with 25,373 people on physiotherapy after stroke comes to the same result: what works are programmes with a high number of repetitions that start from activities of everyday life [36]. That summary names training of sitting balance as the measure with the largest effect among all those examined.

Put into practice this means:

• In the clinic: several short units per day instead of one long one.
• After the clinic: often two to three physiotherapy sessions per week, plus a home programme on the remaining days. That is an example and not a fixed quantity; the amount follows need, goals and progress.
• The home programme lasts 10 to 20 minutes and is tied to an existing habit.
• After physiotherapy ends, practice continues, in a group or alone.

The last point has a reason. In the study of people with progressive cerebellar disease who trained intensively for four weeks, the gains receded within 24 weeks in part of the participants. In 22 of 42 people at least one measurement was still better after 24 weeks than at the start [31].

12.10 What is measured

Without measurement it is hard to say in six months whether anything has changed. The usual measures are:

Of the 40 points of the ataxia scale, 18 fall on gait, stance and sitting [28]. That scale therefore responds above all to changes in the steadiness of trunk and stance.

13. What the studies on rehabilitation show

13.1 How good the evidence is

The evidence on physiotherapy for stroke in the cerebellum is thin. The reason lies in its rarity: of 100 people with a brain infarction, around 2 have a cerebellar infarction [5], and of 100 people with a brain haemorrhage, around 9 have a cerebellar haemorrhage [50]. A study of sufficient size therefore needs many centres over many years.

Most of the knowledge comes from two other sources. One is stroke rehabilitation in general, in which cerebellar infarctions run along without being analysed separately. The other is the treatment of progressive cerebellar diseases, in which the same movement disorder is present while the cause is a different one.

13.2 What has been tested on cerebellar infarction itself

A German study followed 23 people with a fresh infarction confined to the cerebellum over three months [34]. It gives three results:

• During the first days the ataxia was more marked with infarctions in the territory of the superior cerebellar artery than with infarctions in the territory of the posterior inferior cerebellar artery. After three months no difference between the territories could be found any more.
• Unsteadiness in standing had resolved completely after three months. A mild walking disorder remained, above all in pace.
• Part of the participants received treadmill training with increasing speed over two weeks. Between this group and the comparison group no difference appeared.

The authors conclude that two weeks of treadmill training are too little, and that a more intensive coordination training should be tested [34]. That test is still outstanding today.

On recovery after rehabilitation there is an American analysis of 58 people who came to a rehabilitation hospital after a cerebellar infarction or a cerebellar haemorrhage [35]. Independence in everyday life was measured with the Functional Independence Measure, a scale from 18 to 126 points. On admission the mean was 65.5 points, on discharge 89.8 points. Among the 45 people reached after an average of 19.5 months, the median value was 123.5 points.

This analysis was retrospective and had no comparison group. Part of the improvement would have occurred without rehabilitation as well. It included infarctions and haemorrhages together and did not analyse them separately [35].

13.3 What has been tested after a brain haemorrhage

On rehabilitation after a haemorrhage there are more figures than on rehabilitation after a cerebellar infarction. They concern brain haemorrhage at all sites, however, and not the cerebellum in particular. Two analyses compare the course after a haemorrhage with the course after an infarction.

In an American analysis, 1,064 people came to a rehabilitation hospital after a stroke, 871 of them after an infarction and 193 after a haemorrhage. Independence in everyday life was measured with the Functional Independence Measure, a scale from 18 to 126 points. On admission the haemorrhage group scored lower than the infarction group, on average 51 against 59 points. On discharge the two groups no longer differed. The gain was larger in the haemorrhage group, on average 28 against 23 points [64].

An Australian analysis of 718 people arrives at the same picture. The 129 people with a haemorrhage were more limited on admission than the 589 people with an infarction and made larger gains during rehabilitation [65].

Both analyses were retrospective, and in both there was no comparison group without rehabilitation. How much the treatment contributed cannot be read off from them. What they do show: anyone who reaches rehabilitation after a haemorrhage has at least as much room to improve as after an infarction. The starting point is worse on average, and the way up is longer.

For cerebellar haemorrhage in particular there is no study of its own on physiotherapy.

13.4 What the ataxia research adds

In progressive cerebellar diseases, training has been tested several times. Two studies guide the choice of exercises.

Four weeks of coordination training, 16 people. The participants trained balance, trunk control and target movements intensively over four weeks, with supervised sessions and a daily home programme. Measurements were taken before the start, directly afterwards and eight weeks later. The ataxia decreased, and the improvement was still present after eight weeks. People with cerebellar damage alone benefited more than people with additional damage to the feedback pathways [29]. A follow-up of the same group over one year showed that the improvement persisted in those who continued to train [30].

Four weeks of inpatient rehabilitation, 42 people. In this trial the participants were allocated at random to two groups. One started immediately, the other four weeks later. The group treated immediately improved more in ataxia, walking speed and independence in daily life. Truncal ataxia improved more than the ataxia of arm and leg. After 24 weeks, at least one measurement was still better than at the start in 22 of 42 people [31].

A review of 19 studies on the treatment of postural disorders in ataxia summarises: there is evidence of moderate certainty that rehabilitation improves steadiness in standing. Best studied are progressive ataxias and multiple sclerosis. Two of the 19 studies concerned people after stroke [28].

On this basis an international expert group recommends regular coordination and balance training as a fixed component of treatment in cerebellar disorders [33].

13.5 How certain this knowledge is

Five limitations belong to the figures in this section:

• A different cause. The most informative training studies were carried out in people with progressive cerebellar diseases [29][31][32]. After an infarction the tissue improves by itself, in a progressive disease it deteriorates. The transfer is plausible and untested.
• Small groups. The participant numbers lie between 16 and 42 people.
• No blinding. Anyone who trains knows it. Expectation acts on the test results.
• Comparison groups are often absent. After an infarction and after a haemorrhage much improves by itself during the first weeks. Without a comparison group the share of the treatment in that cannot be determined.
• A different site. The figures on rehabilitation after a haemorrhage [64][65] come from people with haemorrhages at all sites in the brain. The great majority of those lay in the cerebrum. For cerebellar haemorrhage they are an approximation.

In summary: that practice helps after a stroke in the cerebellum is well grounded and little tested for this condition. How much it helps is open. That holds for infarction and haemorrhage alike.

14. How things go on

14.1 The first weeks

After the acute phase the symptoms improve quickly in many people. Dizziness and nausea subside within days to weeks. Steadiness in standing returns faster than steadiness in walking [34].

There are two reasons for this early improvement. The swelling around the infarction or the haemorrhage recedes, and tissue that was only impaired works again. Adaptation comes on top: neighbouring areas take over tasks [25]. After a haemorrhage this recession often takes longer, because the blood has to be broken down.

14.2 After three months

In the German study of 23 people with an isolated cerebellar infarction, unsteadiness in standing had resolved completely after three months. A mild walking disorder remained, most clearly in walking speed [34].

The first clear gains can come within the first days and weeks. The largest gains fall into the first three months. Further gains over six and twelve months are possible, in smaller steps [38].

14.3 The figures after a haemorrhage, and how to read them

On cerebellar haemorrhage alone there are few figures on the course. The figures that exist concern brain haemorrhage at all sites and are dominated by haemorrhages in the cerebrum. They are grave, and they cannot be transferred to an individual person.

A summary of 36 population-based studies covering 8,145 people found: of 100 people with a brain haemorrhage, around 40 died within the first month [59]. A second summary of 122 studies found that of 100 people with a brain haemorrhage, around 46 were still alive after one year and around 29 after five years [60].

Three qualifications belong with these figures:

• They describe all brain haemorrhages together, including very large ones and those in very old people.
• They come predominantly from the period before today's care bundles [56].
• They include the first hours and days. A large share of the deaths falls into that period.

Anyone who comes through the acute phase and reaches rehabilitation therefore stands in a different group. There the course resembles that after an infarction, with a larger gain from a worse starting point [64][65].

For cerebellar haemorrhage in particular, survival figures are available from the analysis of 578 people. They are given in section 7.4 and concern a group in which a decision about surgery was being made [50].

14.4 What influences the course

Several influencing factors can be named from the available studies [34][35]:

• The size of the affected area. Larger infarctions went together with more marked ataxia. With haemorrhages, the volume of the haematoma was one of the quantities that related to the course [60].
• Involvement of the brainstem. An additional infarction in the brainstem clearly worsened the prospects [15]. With a haemorrhage the same holds for pressure on the brainstem [51].
• The condition on entering rehabilitation. Those more independent on entry were more independent later as well.
• Other illnesses. The more further illnesses were present, the smaller the progress.
• Clouded consciousness at the start. Those drowsy at the beginning had a less favourable course.

These statements describe groups. No prediction for an individual person can be derived from them.

14.5 What can remain

In some of those affected, symptoms persist. The most common are:

• a slower walking pace and unsteadiness on uneven ground,
• swaying dizziness on rapid head movement or in crowds,
• an imprecise hand for fine activities,
• a slightly changed way of speaking when tired,
• fatigue that sets in sooner than before.

These complaints can be reduced with practice, aids and an adjustment of the daily routine.

15. Everyday life

15.1 Fatigue

Many people are exhausted after a stroke, even after long sleep. A summary of 22 studies with 3,491 people found: of 100 people after a stroke, around 50 report lasting fatigue. The range across the individual studies ran from 25 to 85 out of 100 [44].

Four rules have proved useful:

• Plan the most demanding activity for the time of day with the most energy.
• Set breaks before the exhaustion arrives.
• Split large tasks into sections.
• Keep movement going. Complete rest increases the fatigue.

15.2 Darkness and uneven ground

After a cerebellar infarction the eyes take over part of the balance work. Walking in the dark therefore becomes harder. The same holds for uneven ground, for gravel, for snow and for dense crowds.

What has proved useful in practice: a night light on the way to the bathroom, switching on the light before getting up, firm shoes with a flat sole, a walking stick for unfamiliar routes.

15.3 The home

These points can be settled in one walk-through:

• remove loose rugs or fix them down,
• run cables along the wall,
• fit a grab rail next to shower and toilet,
• put a non-slip mat in the shower,
• set up a shower stool,
• move frequently used things to hip height,
• strengthen the lighting in the hall and the stairwell.

This is set out in detail in the article fall prevention.

15.4 Falls

The risk of falling is raised after a cerebellar infarction, because balance and steadiness in walking are affected. Two things lower it: regular balance training, and an assessment of the other causes of falling. That assessment covers eyesight, medicines, blood pressure on standing and the home, as described under assessing the risk of falling.

If you have fallen, report it in therapy, even when nothing happened. A fall without injury is the most useful piece of information for adjusting the programme.

15.5 Driving

After a stroke, fitness to drive is assessed medically. Until that assessment you drive no vehicle. In Switzerland doctors are permitted to notify the cantonal road traffic authority when they consider a person unfit to drive. Ask in the hospital who carries out the assessment and from when you may drive again.

For the assessment after a cerebellar infarction three points matter above all: the accuracy of the hand on the steering wheel, the eye movements, and attention over a longer period.

15.6 Work

Returning to work usually succeeds step by step. A start at reduced hours with an increase over weeks has proved useful. Speak early with the treating doctor and with the employer about the demands most likely to cause difficulty: screen work over hours, work on ladders, driving, fine handwork, loud surroundings.

15.7 Alcohol

Alcohol acts on the cells of the cerebellum and worsens balance and accuracy of aim for a time. After a stroke in the cerebellum this effect is more noticeable than before, because less reserve is available. In addition, regular alcohol consumption raises blood pressure and with it the risk of a further stroke [46]. After a haemorrhage this second point weighs more heavily, because blood pressure is the most important quantity you can act on there [48].

15.8 Mood and relatives

A summary of 61 studies with 25,488 people found: of 100 people after a stroke, around 31 develop depression [45]. Signs are lasting low mood, loss of interest, disturbed sleep and lack of drive over more than two weeks.

For relatives, what stands in section 5.10 applies in addition: changes in drive, emotional state and planning can stem from the damage in the cerebellum. If you notice such changes, raise them at the next medical review.

16. Preventing a second stroke

After a stroke the risk of a further one is raised. Prevention follows the cause that was found. This is where infarction and haemorrhage part company most widely.

16.1 After an infarction

Depending on the cause, the medicines include one against blood clotting, one against raised blood lipids and one against raised blood pressure [46]. With atrial fibrillation a different clotting medicine is used than with narrowed vessels. Which medicine is right for you is decided by the doctor.

16.2 After a haemorrhage

Blood pressure comes first. Treating raised blood pressure is the most effective measure known against a further brain haemorrhage [48]. It begins in hospital and continues over years. Measurements at home and a measurement over 24 hours show whether the agreed target is being reached.

Blood-thinning medicines are weighed afresh. Anyone who was taking such a medicine before the haemorrhage faces two risks at once afterwards: the risk of an infarction without the medicine, and the risk of a further haemorrhage with it. Two British trials have examined this question.

In one trial with 537 people after a brain haemorrhage, it was decided by lot whether an antiplatelet agent would be restarted. Over a median follow-up of two years, 12 of 268 people in the group with the medicine had a further haemorrhage, against 23 of 268 in the group without it [61]. A disadvantage of restarting could not be shown.

In the other trial with 203 people who also had atrial fibrillation, it was decided by lot whether an oral anticoagulant would be restarted. In the group with the medicine 8 of 101 people had a further haemorrhage, in the group without it 4 of 102. The trial was designed as a pilot and was too small to answer the question [62].

The decision is therefore taken case by case, together with the neurologist. It depends on the reason for the blood thinning, on the position of the haemorrhage, and on whether amyloid angiopathy was found. Never stop such a medicine on your own, and never restart it on your own.

16.3 Way of life, the same for both forms

Proven effective are stopping smoking, regular physical activity, a diet with plenty of vegetables, fruit, pulses and olive oil, and the treatment of blood pressure, blood sugar and blood lipids [46][48].

On activity the recommendation after a stroke is: at least 150 minutes per week at moderate effort, spread over several days [46]. This amount can be reached by walking.

17. When to call 144

Call 144 immediately if one of the following signs appears suddenly:

• You suddenly stand or walk unsteadily and cannot hold yourself up without help.
• You suddenly become severely dizzy, and the dizziness does not stop.
• You suddenly see double, or part of the visual field drops out.
• Your speech suddenly becomes slurred.
• One corner of the mouth droops, or one arm drifts down when held out.
• Your hearing suddenly worsens on one ear and you are dizzy at the same time.
• You suddenly have severe head or neck pain that you do not know in this form.

Note the time at which the symptoms began. That information decides which treatments are possible [17].

If you have already had a stroke in the cerebellum and are at home during the first days: increasing headache, increasing vomiting and increasing drowsiness likewise belong immediately in the emergency department [14][48].

18. Common misunderstandings

• "In a stroke one side is always paralysed." With a stroke in the cerebellum strength is often retained. What stands in the foreground is dizziness, unsteady walking and inaccurate movement [1].
• "A stroke in the cerebellum is the same wherever it is in the cerebellum." The site decides the symptoms and the exercises. Damage at the midline mainly makes the trunk unsteady, damage laterally mainly the arm and the leg [67]. If it reaches the brainstem, swallowing, voice and a pull to one side are added [69].
• "If I sit crooked, I will notice it myself." With a pull to one side, the felt vertical is shifted along with it. In 36 people with an infarction at the lateral edge of the brainstem it was tilted towards the side of the infarction throughout [71]. That is why practice uses a mirror or another vertical from outside.
• "A brain haemorrhage and a brain infarction are the same thing." The causes differ, and the treatment during the first hours goes in different directions [48]. For practice and for everyday life the site within the cerebellum decides.
• "After a brain haemorrhage you must not move." After a haemorrhage too, movement is started early, in short units and with clearance from the treating team [27][48]. Anyone who does not move for weeks loses strength, endurance and balance.
• "Anyone who has had a brain haemorrhage may never take a blood-thinning medicine again." In a trial with 537 people, 12 of 268 in the group that restarted an antiplatelet agent had a further haemorrhage, against 23 of 268 in the group without it [61]. The decision is taken case by case.
• "The examination of the eyes was normal, so everything is fine." The HINTS examination applies only to prolonged dizziness with visible jerking eye movements, and it requires practice. In an analysis that included emergency physicians, around 83 out of 100 causes in the brain were identified [74]. Anyone who cannot stand and walk needs assessment regardless [73].
• "The MRI was normal, so it was not a stroke." Within the first 48 hours the image was normal in 12 out of 100 people with a stroke in the back part of the brain [11]. Where suspicion persists, the image is repeated.
• "After the first week nothing more can happen." The swelling reaches its peak on the second to fourth day [14]. That is why monitoring takes place during this time.
• "The symptoms go away by themselves, practice changes nothing." Part of the improvement occurs without treatment as well. In studies of people with cerebellar disorders, coordination training improved steadiness in standing beyond the natural course [28][29][31].
• "If something is left after six months, it stays for good." The largest gains fall into the first three months. Smaller gains over six and twelve months do occur [38].
• "A wheeled walker is a sign of giving up." An aid increases the distance you cover and lowers the risk of falling. With it you practise more, not less.
• "Dizziness improves if I keep my head still." Keeping the head still permanently does not lead out of the symptoms, because the load then never rises again. Head movements are brought back in step by step, at an intensity that follows your reaction [43].
• "Forgetfulness has nothing to do with the cerebellum." Infarctions in the posterior lateral parts of the cerebellum change planning, switching, language and mood [22][23].
• "Alcohol in small amounts does the cerebellum no harm." Alcohol acts on the same cells that the infarction has affected and worsens balance and accuracy of aim for a time.
• "Physiotherapy for stroke in the cerebellum is well studied." Most training studies come from people with progressive cerebellar diseases [29][31]. Little has been tested on cerebellar infarction itself so far [34], and nothing on cerebellar haemorrhage.

19. What to bring to therapy

For the first session these details are useful:

• the hospital discharge report with the site and the type of the stroke, that is, infarction or haemorrhage,
• from it in particular which vascular territory or which part of the cerebellum is affected, and whether the brainstem was involved,
• whether a swallowing disorder was found in hospital and whether speech and language therapy was involved,
• the current list of medicines,
• three activities you miss most in everyday life,
• whether and when you have fallen,
• your walking aids, if you have any,
• the shoes you wear in everyday life.

Useful questions for the therapist:

• Which site in my cerebellum is affected, and what does that mean for the choice of exercises?
• Which measurements do we record today so that we can compare in three months?
• What do I practise at home, how often and for how long?
• How do I recognise that an exercise is too hard?
• What do I do if I become dizzy while practising?
• When do we talk about a walking aid?

20. In summary

A stroke in the cerebellum comes in two forms. With an infarction a vessel closes; with a haemorrhage one bursts. Of 100 people with a brain infarction, around 2 have a cerebellar infarction [5]; of 100 people with a brain haemorrhage, around 9 have a cerebellar haemorrhage [50].

The symptoms depend on the site. With an infarction the site can be assigned to the three cerebellar arteries: spinning dizziness and headache with the territory of the posterior inferior artery, hearing loss with the territory of the anterior inferior artery, unsteady walking and slurred speech with the territory of the superior artery. A haemorrhage does not keep to these territories; it usually arises deep within one half of the cerebellum [47]. More often than with an infarction, severe headache and vomiting stand at the beginning.

Within the cerebellum, the exact place decides. Damage at the midline mainly makes trunk and standing unsteady, damage laterally mainly the arm and leg of the same side, damage below mainly dizziness and steadiness of gaze [67]. If the infarction reaches through the posterior inferior artery into the brainstem, Wallenberg syndrome arises: crossed sensory loss, hoarseness, difficulty swallowing, a pull to one side, with strength preserved [69]. There, swallowing and the work on the vertical come before everything else.

Because weakness is frequently absent, a stroke in the cerebellum is often taken for an irritation of the balance nerve. Of 100 people who came to an emergency department because of dizziness and had a stroke, around 39 were classified as something else at first contact [12]. Computed tomography shows a haemorrhage at once [54]; a fresh infarction it often does not yet show, and a normal MRI does not rule one out during the first hours either [11]. The examination of the eyes helps where the dizziness persists, the jerking eye movements are visible and a practised person examines; outside that it is not a test that rules anything out [73][74].

During the first days it is about the room available in the narrow posterior cranial fossa. With an infarction the swelling reaches its peak on the second to fourth day [14]. With a haemorrhage the shortage of space is there at once, and the bleed can still grow during the first hours [53]. That is why monitoring takes place, and why it is close from the start with a haemorrhage.

Treatment during the first hours parts company. With an infarction the clot is dissolved or pulled out [16][17]. With a haemorrhage the blood pressure is lowered and disturbed clotting is restored [55][57]. With increasing pressure, a drain for the cerebrospinal fluid and an opening of the skull come into question for both forms, and with a haemorrhage evacuation of the haematoma as well [50]. The two procedures solve different problems: where there is pressure on the brainstem, a drain on its own may not suffice [14].

In rehabilitation both forms come to the same building blocks: balance, walking, accuracy of aim and steadiness of gaze. Which of them comes first is indicated by the site (section 12.1). Because the cerebellum performs the internal matching of movement, practice needs many repetitions and feedback from outside [24]. Damage involving the deep-lying cerebellar nuclei is compensated less well than damage to the cerebellar cortex [67].

The course is favourable in many people. In a study of 23 people with an isolated cerebellar infarction, unsteadiness in standing had resolved completely after three months while a mild walking disorder remained [34]. After a haemorrhage the starting point is worse on average and the gain during rehabilitation larger [64][65]. The evidence on physiotherapy comes predominantly from studies of other cerebellar disorders. It supports regular coordination and balance training and leaves open how large the gain is with stroke in the cerebellum.

Prevention is where the two differ most clearly. After an infarction it is about clotting inhibition, blood lipids and blood pressure [46]. After a haemorrhage, blood pressure comes first, and blood-thinning medicines are decided on afresh [48].

What you influence most: the regularity of practice over months, the prevention of a further stroke with medicines and activity, and the adjustment of home and daily routine to what applies now.

References

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Transparency

• Authorship: Roger Hilfiker
• AI support: the literature search and the text draft were produced with Claude (Anthropic). Roger Hilfiker checked all statements, figures and sources and revised the text.
• Created: 22 August 2026
• Last updated: 23 August 2026. The article first covered cerebellar infarction only and lived at /en/wissen/kleinhirninfarkt/. On 23 August 2026 cerebellar haemorrhage was added, because both forms affect the same place and lead to the same rehabilitation. The old address redirects to the new one. On the same day, Wallenberg syndrome (section 4.2), the pull to one side (section 5.3), the swallowing disorder (section 5.6) and the overview of what the site means for practice (section 12.1) were added. After a second external clinical review on the same day, the statements on the examination of the eyes (section 6.2), on imaging (section 6.3), on the procedures for lack of space (section 7.4) and on lowering the blood pressure (section 10.2) were qualified, because they had been put too definitely. A third review on the same day added the four occasions for surgery in cerebellar haemorrhage including the volume above 15 millilitres (section 7.4), placed the treatment protocol of 2001 as historical, and brought the sentence on computed tomography in the summary into line.
• Sources: the 78 works in the reference list. All DOIs were checked against the Crossref register.
• Conflict of interest: the practice offers physiotherapy for dizziness, balance disorders and neurological conditions as a service. This article recommends exercise therapy. We disclose this so that you can take it into account while reading.
• Funding: Physiotherapie Tschopp & Hilfiker, 3902 Glis. The article was produced from the practice's own resources.
• Next review: planned for August 2028