Hemicraniectomy is a surgical procedure where a large flap of the skull is removed and the dura is opened; this gives space for the swollen brain to bulge and reduces the intracranial pressure.Decompressive hemicraniectomy and duroplasty for malignant MCA territory infarction is intended to prevent the death spiral by normalizing intracranial pressure, restoring compromised flow in the penumbra and adjacent vascular territories, and restoring the midline position of the brain stem and diecephalon. The procedure is not new, but was performed rarely for MCA infarction before the 1990s, primarily because of concerns that it would result in survival with overwhelming neurological impairment and handicap. With improvements in postoperative critical care, however, there has been a resurgence of interest in hemicraniectomy over the past 10 years.The aforementioned pooled analysis reported by Vahedi et al earlier this year is a landmark publication because it is the first to demonstrate that hemicraniectomy can be a life-saving procedure.