Large hemispheric strokes may swell, and decompressive craniectomy is the only way to prevent mortality from mass effect. Medical management with osmotic diuretics is often unhelpful. Decompressive craniectomy should be considered in patients less than 60 years of age, with mass effect on CT scan and evidence of early neurological decline. But after this procedure severe disability remains, an issue of utmost importance to address with a proxy. Not everyone is persuaded of the value of this last-resort measure. It is important to consider who benefits and how much disability can be expected and tolerated.