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Cerebellar infarct clinical presentation

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cerebellar infarction posterior circulation stroke diagram PICA AICA SCA territories

Cerebellar infarction usually has a sudden onset and may initially resemble a peripheral vestibular disorder.

Typical clinical presentation

  • Acute dizziness or vertigo, often severe and continuous
  • Nausea and repeated vomiting
  • Gait and truncal ataxia: broad-based, unsteady gait, inability to walk or sit unsupported in severe cases
  • Ipsilateral limb incoordination: dysmetria, intention tremor, dysdiadochokinesia
  • Nystagmus and other ocular-motor abnormalities
  • Dysarthria: slurred or scanning speech
  • Occipital headache, sometimes with neck pain
  • Dysmetria and hypotonia on the affected side
  • Less commonly: hearing loss, tinnitus, or persistent hiccups, particularly with AICA-related infarction
Many patients remain alert and have no obvious limb weakness or sensory loss. Thus, isolated acute vertigo with severe imbalance can be the presenting syndrome and is commonly mistaken for vestibular neuritis. Tintinalli's Emergency Medicine, lines 1937-1939; Symptom to Diagnosis, lines 2955-2985.

Localizing clues

  • Cerebellar signs are usually ipsilateral to the infarct.
  • PICA territory: vertigo, nausea/vomiting, occipital headache, gait ataxia. If the lateral medulla is involved, there may be dysphagia, hoarseness, Horner syndrome, facial sensory loss, and crossed body sensory findings.
  • AICA territory: vertigo, ataxia, nystagmus plus ipsilateral facial weakness or sensory symptoms and hearing loss.
  • SCA territory: prominent ipsilateral limb ataxia, dysarthria, and dysmetria, sometimes with less prominent vertigo.

Danger signs of a large cerebellar infarct

Edema in the confined posterior fossa can compress the brainstem or obstruct the fourth ventricle, causing hydrocephalus. Watch for:
  • Drowsiness, confusion, or declining consciousness
  • New gaze palsy or cranial nerve deficits
  • Worsening headache/vomiting
  • Respiratory irregularity
  • Rapid deterioration to coma
This is a neurological emergency requiring urgent stroke assessment. A normal early non-contrast CT does not rule it out; diffusion-weighted MRI is more sensitive when suspicion remains high. Tintinalli's Emergency Medicine, line 1939.
A recent evidence review on large cerebellar infarctions focuses on the importance of recognizing mass effect and timely neurosurgical management (2026 systematic review).
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