In the past decade, there have been considerable advances in the endovascular management of patients with acute ischaemic stroke. However, notwithstanding the clear cut evidence for endovascular therapy there remain major logistical challenges in providing widespread and timely access to this therapy across many healthcare systems. For those patients who either fail endovascular therapy, or who present outside the time dependent therapeutic window, there is a risk that they will go on to develop life threatening cerebral oedema, so-called malignant middle cerebral artery infarction. The prognosis for these patients is poor with a mortality rate in the region of 80%, without specific treatment. In these circumstances, consideration may be given to performing a decompressive hemicraniectomy as a lifesaving intervention. Unfortunately, unlike endovascular therapy that has the potential to reverse a neurological deficit, surgical decompression will only reduce mortality and the concern has always been that many survivors will be left with an unacceptable level of disability. There have now been a number of randomized controlled trials that have demonstrated this outcome, and this presents a number of ethical issues that require consideration when faced with a patient who clinically deteriorates following an ischaemic stroke.