Background & Objectives: Malignant middle cerebral artery (MCA) stroke constituting 5% of all strokes carries a high mortality across the world. We aimed to study predictors of malignant MCA stroke outcome, especially decompressive surgery in a developing country scenario. Methods: This was a prospective study design where patients with malignant MCA stroke (defined as imaging-CT/ MRI showing infarct involving >2/3rd MCA territory) admitted within 7 days of illness to SCTIMST, between January 2010 and December 2014 (5 years) were recruited. Clinical and imaging data, surgical details, in hospital complications and discharge outcome were collected. Follow-up data was collected at 3 and 12 months post-stroke. Results: We had 74 patients of malignant MCA territory strokes, 42 operated and 32 non-operated, who were comparable at baseline, except for age and stroke severity. At 3 months, deaths were more among the non-operated group (63% in non-operated vs 23% in operated group, p=0.02), while functional outcome was comparable. At 1 year follow-up, age below 60 years, lower stroke severity at onset and decompressive surgery were found to be independent predictors of good outcome. (p=0.04). Delayed surgery group, albeit small had a better 1 year outcome in comparison to the medical arm. Conclusions: Early functional outcome in the decompression group did not differ from the medically treated patients, other than mortality benefit. However, at 1 year, patients with age<60 years, lower stroke severity and decompressive surgery had a better morbidity and mortality outcome, indicating long term benefit of this life saving procedure in developing country scenario as well.