Can inevitable credence of caregivers and surgeon’s instinct dominate existing evidence based practice?

Cerebrovascular accidents are leading cause of mortality and disability throughout the world. Malignant cerebral edema with hemorrhagic stroke constitutes a significant proportion of these patients. Ever since Cushing performed first decompressive craniotomy (DC), the confusion on appropriate management of malignant cerebral edema continues. The present era of evidence based management and quality of life care has manipulated the literature with heterogeneous results and conundrums. Presently, the famous trials talk about functional improvement after DC and advantages of tracking secondary brain injury pathogenesis highlighting the insufferable outcome of various trials. Being a neurosurgeon, I believe that each one of us must have face a situation wherein, either caregiver’s forceful cultural belief or sometimes our own inner conscience push us against all available evidences; and a surprisingly better than expected results are achieved. We never report these cases but the question persistently troubles us is “whether to operate or not?” in a case of malignant cerebral edema.