There continues to be considerable amount of interest in decompressive craniectomy however its use is controversial. It is technically straightforward however it is not without significant complications and although there is currently unequivocal evidence available that it can be a life saving intervention, evidence that outcome is improved over and above standard medical therapy is less forthcoming. This narrative review considers the current role of decompressive craniectomy in the management of neurological emergencies and focuses on four specific questions, namely; (i) Is the decompressive craniectomy a life saving procedure? (ii) Does decompressive craniectomy improve outcome? (iii) Are there any risks associated with decompressive craniectomy? (iv) How do patients feel about their eventual outcome?Finally the future directions for the use of decompressive craniectomy are explored. © 2013 Australian College of Critical Care Nurses Ltd.