Mr. Johnson is a 62-year-old man with no prior past medical history who is admitted to the intensive care unit (ICU) after suffering a large cryptogenic stroke in the past 24 hours, with the majority of his left middle cerebral artery (MCA) now infarcted on neuroimaging. Despite his being globally aphasic with a right hemiparesis, a gaze deviation to the left, and a right-sided hemianopsia, his eyes initially open to voice easily, he has symmetric pupils, and he is protecting his airway. Several hours later in the ICU, the nurse notes that he still has symmetric pupils, but his eyes now require noxious stimulation to open, and he seems to be snoring. His serum sodium is 145 mEq/L; a repeat computed tomography scan of the head (Figure 11.1) shows that he has developed an interval increase in cerebral edema and now has a few millimeters of left-to-right midline shift. His family “doesn’t want him to die” and is very hopeful that he might improve in the future, saying that he is a very active 62-year-old. You walk into a meeting with the family after ordering mannitol and being told by the nurse that someone on the team had already mentioned the possibility of decompressive craniectomy to them.