Severe head injuries in children (under 15 years of age) have many features that differentiate them from head injuries in adults. In such cases, non-surgical treatment cannot always prevent fatal herniation. We report on seven cases of children with severe head injury, presenting with decorticate posturing and treated by unilateral decompressive craniectomy. The aim of the unilateral decompressive craniectomy was to decompress the midbrain and the brainstem. Post-operatively, all patients showed good recovery within 5 weeks (Glasgow Coma Scale score 15). The alternative treatment modalities are discussed critically in an attempt to determine the value of the unilateral decompressive craniectomy procedure and to define the clinical parameters that might identify those children most likely to benefit from this technique. CONCLUSION: the unilateral decompressive craniectomy has an advantage over non-surgical treatment of children with severe brain injury and should be considered in their management.