Traumatic brain injury (TBI) remains a significant global health burden, associated with high mortality and morbidity, particularly in developing nations. Decompressive craniectomy (DC) has emerged as a crucial surgical intervention for severe TBI cases with refractory intracranial hypertension, aiming to reduce pressure and potentially improve outcomes. This prospective analytical study, conducted at a single tertiary care centre in India, evaluated the outcomes of DC in 52 patients with severe TBI and midline shift. The primary outcomes assessed were mortality and favourable outcomes based on the Glasgow Outcome Scale (GOS) at various follow-up points. Factors such as age, pre-operative GCS, pupillary reactivity, midline shift, and CT scan findings were analysed for their influence on outcomes. The study revealed a mortality rate of 71.1% at 6 months. However, 21.2% of patients achieved a good recovery. Pre-operative GCS, pupillary reactivity, and midline shift were identified as significant predictors of outcomes. These findings underscore the potential of DC to improve outcomes in severe TBI, while also highlighting the need for further research, particularly randomized controlled trials, to establish definitive evidence for its efficacy.