Brain areas that swell significantly after a stroke may create life-threatening conditions and are associated with a poor prognosis. Therefore any measure that relieves significant compression and intracranial pressure increase is warranted because the main therapeutic principle aims at avoiding secondary and possibly permanent brain and brainstem injury caused by mass effect and shift. Medical treatment options have not been validated well, but neurosurgical management in the form of decompressive craniectomy for hemispheric supratentorial strokes has been tested prospectively in clinical trials and proved efficient and beneficial in terms of reduced mortality (all age groups) and improved functional outcomes (for ages 60years). Decompressive suboccipital craniectomy for symptomatic swelling and/or hydrocephalus associated with cerebellar strokes is also considered highly effective in all age groups. Close monitoring (clinically and radiologically) of patients at high risk who have had stroke is most important to allow for timely appropriate decompressive surgery for symptomatic stroke-associated brain swelling and herniation.