Does decompressive hemicraniectomy improve survival without severe disability in patients aged >60 years with malignant middle cerebral artery (MCA) infarction? Patients were randomized to undergo hemicraniectomy within 48 h of symptom onset or receive conservative medical treatment. The primary outcome was survival with a modified Rankin Scale (mRS) score of 4 or lower at 6 months. The trial demonstrated that hemicraniectomy significantly improved survival compared to conservative treatment but resulted in higher rates of survivors with mRS scores of 4 or 5, indicating severe disability. While some survivors reported acceptable quality of life, the clinical benefit must be weighed against the likelihood of significant disability. DESTINY II emphasized the importance of patient and caregiver preferences when deciding on hemicraniectomy in older patients with malignant MCA infarction.