Background and purpose: The prognosis of malignant middle cerebral artery infarctions (MCA) is poor. The poor prognosis is attributable to the severe cerebral edema that causes a brain herniation and death. Decompressive surgery reduces mortality and may further improve patient outcomes. However, the safety and effectiveness of decompressive surgery in patients who underwent combined intravenous (IV) thrombolysis and endovascular stroke treatment are not certain. Moreover, the evidence on the timing of decompressive surgery is lacking.