Abstract Background: About 10 percent of ischemic strokes are defined as a malignant one due to associated massive brain edema which is severe enough to produce elevated intracranial pressure and brain herniation. Decompressive Craniectomy (DC) with duraplasty is a surgical technique that involves the creation of extra roomy space and incision of the tight dural covering the brain allowing swollen brain tissue to herniate outwards to reduce the Intracranial Pressure (ICP). Aim of Study: This study aims to share the experience of performing decompressive craniectomy in the treatment of malignant Middle Cerebral Artery Infarction (MMCAI) >48 hours after stroke with an analysis of the results and prognostic factors. Patients and Methods: From January 2016 to June 2018, we performed a decompressive craniectomy in eleven patients with massive middle cerebral artery infarction. Retrospectively we reviewed the clinical and radiological data, Glasgow coma scale at admission, pre and post-operatively. Serial Computed Tomography (CT) with measurement of midline shift pre and post-operatively. Patients were evaluated according to the following factors: Age, sex, the time between admission and surgery, the time between deterioration and surgery, the pre and post-operative Glasgow coma scale, pre and post-operative midline shift on CT scan, dominancy, and Glasgow outcome scale. Results: Eleven patients (11) have been operated on by decompressive hemicraniectomy and duroplasty, there were no significant changes in outcome in relation to the admission GCS, GCS (p=0.2599) or in GCS (p=0.3713), but there was a significant correlation between the pre-operative GCS and outcome and decompressive craniectomy leads to highly significant relieve of the midline shift (p < 0.000). No significant correlation was detected between the time interval elapsed between admission and the time surgery and patient outcome (p=0.3032), but there was also a significant correlation between the time interval between patient deterioration and time of decompressive craniectomy and patient outcome (p=0.92161). Conclusion: Very strict close observation of patients with Malignant Middle Cerebral Artery (MMCA) infarction in the Neuro ICU is highly recommended and surgery should be done as early as possible before the clinical deterioration of the brain herniation for better benefit. Decompressive craniec-tomy could be a life-saving procedure for large hemispheric infarction but postoperative morbidity and quality of life are the main challenges. Although early surgery is recommended by many studies but still DC even after 48 hours may be a life-saving procedure for some patients especially those operated on within a small time window once the clinical deterioration has happened but the post-operative morbidity and quality of life are the main challenges.