In patients with traumatic brain injury (TBI) and refractory intracranial hypertension, does decompressive craniectomy improve outcomes compared to medical management alone? The RESCUEicp trial, a multicenter randomized controlled study, investigated this question in patients with refractory intracranial hypertension above 25 mm Hg despite optimal medical therapy. Patients were randomized to undergo decompressive craniectomy or continued medical management. The trial found that decompressive craniectomy significantly reduced mortality; however, survivors in the surgical group had higher rates of severe disability, vegetative state, or dependence compared to the medical group. These findings highlight the dilemma of balancing improved survival with the risk of significant neurological disability. The study underscores the need for careful patient selection and individualized decision-making when considering decompressive craniectomy for TBI with refractory intracranial hypertension.