About 15% of the patients with the middle cerebral artery or internal carotid artery territory acute infarction can lead to massive cerebral edema with raised intracranial pressure and progression to coma or death within 3-5 days of the original ictus. Decompressive wide unilateral frontotemporoparietooccipital craniectomy with duroplasty should be given in appropriate time if patient had no effect in combating transtentorial herniation with medical therapy such as mannitol and hyperventilation. Occlusion of posterior inferior cerebellar artery or vertebral artery and superior cerebellar artery can evolve into life-threatening brainstem compression or hydrocephalus from postinfarct cerebellar edema. Suboccipital decompressive craniectomy with resection of necrotic cerebellar tissue or extraventricular drainage may be an effective lifesaving procedure in case of no improvement with medical therapy. Very few cases of acute infarction with embolic occlusion of main trunk of middle cerebral artery which confirmed by angiography within 6-8 hours after onset may be considered to have embolectomy by open craniotomy.