1.9.4 People with any of the following rarely require surgical intervention and should receive medical treatment initially: small deep haemorrhages lobar haemorrhage without either hydrocephalus or rapid neurological deterioration a large haemorrhage and significant comorbidities before the stroke a score on the Glasgow Coma Scale of below 8 unless this is because of hydrocephalus posterior fossa haemorrhage. [2008] Decompressive hemicraniectomy 1.9.5 Consider decompressive hemicraniectomy (which should be performed within 48 hours of symptom onset) for people with acute stroke who meet all of the following criteria: clinical deficits that suggest infarction in the territory of the middle cerebral artery, with a score above 15 on the NIHSS decreased level of consciousness, with a score of 1 or more on item 1a of the NIHSS signs on CT of an infarct of at least 50% of the middle cerebral artery territory: with or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side or with infarct volume greater than 145 cm3 , as shown on diffusion-weighted MRI scan. [2019] 1.9.6 Discuss the risks and benefits of decompressive hemicraniectomy with people or their family members or carers (as appropriate), taking into account their functional status before the stroke, and their wishes and 2022 NICE has produced patient decision aids to support discussions about decompressive hemicraniectomy. 1.9.7 People who are referred for decompressive hemicraniectomy should be monitored by appropriately trained professionals skilled in neurological For a short explanation of why the committee made these 2019 recommendations and how they might affect practice, see the rationale and impact section on decompressive hemicraniectomy for people with acute stroke. Full details of the evidence and the committee's discussion are in evidence review H: surgery (decompressive hemicraniectomy). 