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Objective: To present our experience in using decompressive craniectomy (DC) among severe traumatic brain injury (TBI) patients during operation and to discuss its indication.Methods:From October 2008 to May 2009,41 patients aged between 18 and 75 years with severe TBI were included in this study.They underwent DC or non-DC (NDC)according to their intraoperative findings.Postoperative intracranial pressure (ICP),complications,requiring second operation or not and outcomes were observed.Results: Fifteen patients underwent DC and 26 patients did not.The average postoperative ICP of each patient was lower than 20 mm Hg.For patients received DC,2had seizures after operation and 1 developed cerebrocele in the follow-up period; only 1 NDC patient had post-traumatic seizures,but none of them had delayed haematoma,cerebrospinal fluid fistula,cerebrocele or infections.At the end of follow-up,10 patients died,6 had the GOS of 2,2 of 3,9 of 4 and 14 of 5.Conclusions: DC is necessary to manage fulminant intracranial hypertension or intraoperative brain swelling.If there was not brain swelling after removal of the haematoma and necrotized neural tissues,it is safe to replace skull flap.The intraoperative finding is an important factor to decide whether to perform DC or not.