Among medical therapies, osmotherapy with colloidal agents (mannitol, glycerol) or crystalloid agents (hypertonic saline) is reasonable for patients whose condition is deteriorating due to mass effect and herniation from large anterior circulation hemispheric or cerebellar infarcts, especially as bridging therapies to definitive surgical intervention. Hyperventilation and hypothermia may also be reasonable, though are of less certain benefit. Corticosteroids have not been found helpful. Agents that block sulfonylurea receptor-mediated cellular swelling, such as intravenous glyburide, have shown promise but require pivotal trial testing. Ventriculostomy is useful to treat non-communicating hydrocephalus arising from obstruction of CSF flow pathways by swollen brain infarcts. But in select large cerebellar infarcts, ventricular drainage alone may exacerbate upward herniation of swollen cerebellar tissues, and suboccipital craniectomy along with ventricular drainage is preferred. Suboccipital craniectomy, often with resection of infarcted tissue, is recommended for massive cerebellar infarcts that may herniate directly into the brainstem, on the basis of observational evidence. Hemicraniectomy for brain oedema associated with large anterior circulation hemispheric infarction is life-saving, but survivors often have severe disability, especially when over age 60. If pursued, hemicraniectomy is generally best performed within 48 h of onset and before development of advanced herniation and neurological deterioration.