Tehran University of Medical Sciences Current Journal of Neurology 2717-011X 13 2 2014 06 15 101 104 Humain Baharvahdat Department of Neurosurgical, School of Medicine, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. Hamid Etemadrezaie Department of Neurosurgical, School of Medicine, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. Samira Zabyhian Department of Neurosurgical, School of Medicine, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. Zahra Valipour Neurology Research Group, Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Babak Ganjeifar Department of Neurosurgery, School of Medicine, Emdadi Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. Seyed Mohammad Mousavi Mirzaye Department of Neurology, School of Medicine, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. Payam Sasannejad Department of Neurology, School of Medicine, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. Kavian Ghandehari Department of Neurology, School of Medicine, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. 2015 10 14 Background:  Intravenous  recombinant  tissue plasminogen  activator  (rt-PA) is an approved  treatment for acute ischemic stroke within 4.5 h of symptoms onset. Decompressive craniectomy (DC) has been  shown  as an effective  therapeutic  modality in malignant  middle cerebral  artery (MCA) infarction. As rt-PA could result in hemorrhagic  complication during or after any surgery DC may be associated with severe bleeding after intravenous thrombolysis. Case Description: A 57-year-old woman was presented 90 min after the sudden  onset of left hemiplegia. Despite intravenous  thrombolytic therapy, she lost consciousness within 48 h and brain CT scan showed a right malignant MCA infarction associated  with a small bleeding. DC was performed  without  any complication. The patient improved dramatically. Conclusion: DC could be done safety for malignant  MCA infarction after unsuccessful intravenous thrombolytic therapy  even  the later was complicated  with  intra- infarction hemorrhage. https://ijnl.tums.ac.ir/index.php/ijnl/article/view/614 https://ijnl.tums.ac.ir/index.php/ijnl/article/download/614/188