This chapter examines the utility of performing a decompressive craniectomy in pediatric patients who present with severe traumatic brain injury but no mass lesion (e.g. cerebral edema). Evidence discussed includes randomized controlled trials in adults, retrospective comparison studies in children, and retrospective case series in adults and children. Additionally, the chapter addresses prognostic factors that suggest when decompressive craniectomy will not be effective. Finally, we touch on questions of quality of life in patients who survive such injuries/surgery but have life-long neurological deficits. The final recommendation is that in pediatric patients with severe TBI and no mass lesion, decompressive craniectomy may be useful in situations where the patient has an acute neurological decline (e.g. impending herniation) or medically refractory elevated ICP. (evidence quality poor; weak recommendation).