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The authors have considered the capabilities of decompressive craniotomy in malignant ischemic stroke treatment. Malignant stroke is understood to be stroke with extensive cerebral ischemia, post-ischemic edema formation, and the presence of lateral and/or axial cerebral displacement that is mainly due to proximal middle cerebral artery occlusion. There were highlighted the etiology and pathogenesis of this type of cerebrovascular disease. The disease predictors (clinical, radiological, laboratory) were described in detail, the most significant among them being emphasized. Based on randomized multicenter studies the researchers determined the indications, contraindications and selection criteria of patients when this surgical approach is used to treat malignant ischemic stroke. Surgical approach was demonstrated to enable to reduce case mortality, and improve functional treatment outcomes and results. There were described in detail the technique and peculiarities of decompressive craniotomy in this pathology, as well as the main postoperative complications. The authors considered the problem of optimal surgery time, and suggested an original treatment algorithm for patients with this pathology.