Decompressive surgery with hemicraniectomy and durotomy for malignant MCA infarction remains a salvage procedure but can be associated with reasonable clinical outcomes in highly selected patients. This selection of patients appropriate for intervention is of the utmost importance, but exact criteria remain to be defined; older age and increased numbers of associated medical comorbidities seem to define a group of patients who would not derive long term benefit, however. The determination as to whether or not surgery is equally beneficial for dominant or nondominant hemispheric infarction is hampered by lack of good comparative data, but selected case series suggest that some patients who have dominant hemispheric infarction achieve a reasonable degree of independence. Although a well-defined principle of stroke practice is that "time is brain," there are no clear data as to when intervention should be done, as there are some patients who have large MCA infarction and who may not progress to cerebral herniation. Clinicians managing the growing population of patient status post hemicraniectomy should also be aware of this process of the syndrome of the trephined and the potential for resolution that may prompt earlier cranial reconstruction. At present, the decision to proceed with this aggressive intervention of hemicraniectomy and durotomy for large ischemic infarction remains a case-by-case individualized approach, based on patient and family preferences and clinicians' subjective perspective as to patients' potential for clinical recovery.