After traumatic brain injuries, decompressive craniectomy is an increasingly common procedure used to reduce intracranial pressure, but there have been few randomised studies of this invasive technique. Australian and Saudi researchers randomly assigned 155 adults with severe traumatic brain injuries and intracranial hypertension that had not responded to first-tier therapy, to either standard care or decompressive craniectomy. The latter did reduce intracranial pressure and length of intensive care unit stay, but increased the likelihood of a poor outcome 6 months after the injury. The proportion of people who died within 6 months of their injury was similar in both groups. Researchers were surprised that craniectomy was linked to fewer favourable outcomes. “Our findings differ from those of most non-randomized studies of decompressive craniectomy and are contrary to our hypothesis”, wrote Dr James Cooper of Alfred Hospital, Melbourne, and colleagues.