Malignant middle cerebral artery (MCA) infarction occurs in about 10% of all patients with supratentorial ischemic strokes. The infarction involves the entire MCA territory. Due to the consequences of severe brain edema, brain herniation, elevated intracranial pressure (ICP), and midline shift, these events carry a mortality rate of up to 80%. No clinical trials have been conducted to study the efficacy of the osmotic agents such as mannitol or hypertonic saline. Furthermore, aggressive use of such treatments may be detrimental. Surgical decompression has previously been proposed as a way to relieve the vicious cycle of malignant cerebral edema and reduced cerebral perfusion. Its use in relieving ICP is also controversial. Recently, a pooled analysis of three independent European trials has shown that decompressive hemicraniectomy is clearly beneficial in reducing mortality from large hemispheric infarctions. Although controversies still exist on its indications, surgical decompression can effectively reduce ICP, reduce mortality, and improve neurologic outcomes in selected patients with a malignant MCA stroke syndrome.