The process of informed consent is considerably complex in acute stroke. In this issue of J Neurol Neurosurg Psychiatry, Hofmeijer and colleagues1 examined informed consent for hemicraniectomy in malignant stroke, a particularly difficult clinical scenario that underscores the uncertainty, limited evidence and complexity that clinicians must convey to patients and families regarding stroke, and seemingly heroic measures that have recently allowed for positive outcomes in select cases (see page 1124). Hemicraniectomy or decompressive surgery for malignant stroke superimposes further complexity. Such a surgical option is entertained only when the perceived …