Recent studies suggest that a total ischemic brain tissue volume > 300 cm(3) observed on CT is a significant indicator of an unfavorable outcome with a sensitivity of 100% after DC in patients with malignant ischemic stroke. In this article, we reported a 61-year-old male patient with poor preoperative clinical status and most predictive factors pointed to an unfavorable outcome who nonetheless demonstrated an acceptable functional recovery after DC. On cranial computer tomography, CT angiography, and diffusion MRI, his cortical and subcortical MCA and anterior cerebral artery (ACA) vascular territories showed infarctions that extended toward the basal ganglion. The volume of the ischemic cerebral tissue was calculated using ROI (region of interest) manager tool of OsiriX (R) DICOM image processing software (Pixmeo SARL, Bernex, Switzerland) and found to be 411 cm(3). Decompressive craniectomy decision-making depending solely on the radiological volume of the ischemic brain can be misleading in the management of patients with malignant ischemic stroke.