They noted that patients would not be able to be involved at the time because of the severity of the stroke, so the family or carers would be responsible for making the decision. In deciding whether to opt for surgery, considerations should include pre-stroke functional status, because surgery would not be appropriate for people with severe disability before stroke. The committee noted that although some of the trials included people who had surgery as 2022 long as 96 hours after symptom onset, the benefits in terms of reduced mortality and improved functional outcome were largely driven by studies that only allowed surgery up to a maximum of 48 hours after onset. Therefore, it agreed to retain the reference to surgery being performed within 48 hours of onset from the original recommendations. The committee also reviewed the criteria used to determine eligibility for hemicraniectomy from NICE's stroke guideline published in 2008. It was agreed that these were still appropriate and reflect the populations included in the studies used to inform the new recommendations. The committee agreed that although the cost effectiveness of decompressive hemicraniectomy remains uncertain, it should be considered for some people because of the clear mortality benefit and the improved functional outcomes. Shared decision making between physicians, surgeons, families and carers is important given the high likelihood of residual moderate or severe disability after surgery. How the recommendations might affect practice In current practice, around 5% of people on the stroke unit are referred for decompressive hemicraniectomy. Decompressive hemicraniectomy is currently considered for those aged under 60. This recommendation will require a change from current practice by all providers. The guidance will also require healthcare professionals to take into account people's pre-stroke functional status and to have a discussion about the risks and benefits. 