The most important acute phase complication of massive cerebral infarction is cerebral herniation secondary to brain edema. In the past decade, there has been heightened interest in surgical treatment of this problem with the use of the techniques of hemicraniectomy and dural augmentation. In this article, we review the theoretical and clinical data supporting the use of hemicraniectomy in malignant cerebral infarction and the range of outcomes expected in patients who undergo this procedure.