Background An injury to the brain or intracranial hemorrhage may cause it to swell. The pressure within the skull then increases as the brain has no room to expand; this excess pressure, known as intracranial hypertension, can cause further brain injury. High intracranial pressure (ICP) is the most frequent cause of death and disability in brain-injured patients. If high ICP cannot be controlled using general or first-line therapeutic measures such as adjusting body temperature or carbon dioxide levels in the blood and sedation, second-line treatments are initiated. One of these is a procedure called decompressive craniectomy (DC). DC involves the removal of a section of skull so that the brain has room to expand and the pressure decreases. Patients and methods We studied 20 patients who presented to the Neuroemergency Unit in AL-Azhar University Hospitals in Cairo and Damanhur Medical National Institute in Damanhur from January 2017 to December 2017 with severe traumatic brain injury with clinical and radiological evidence of increased ICP and indicated for DC. All patients were followed up postoperatively in ICU with serial follow-up computed tomography. Consciousness level was evaluated using the Glasgow Coma Scale and Glasgow outcome score. Results The overall mortality was five (25%) cases, four severely disabled (20%), and 11 (55%) patients had favorable outcome. Conclusion In 20 cases with severely raised ICP resistant to conservative management, DC allowed 55% of cases to be discharged from hospitals with mild degree of disability for rehabilitation.