Intracranial hypertension is a critical condition often resulting from traumatic brain injury or malignant middle cerebral artery ischemia, necessitating surgical intervention when conservative treatments fail. This study compares the efficacy of decompressive craniectomy (DC) and expansion craniotomy (EC) in managing cerebral edema. Sixty-three patients, 52 undergoing DC and 11 undergoing EC, were evaluated for changes in brain volume, midline shift, and other key parameters using pre- and post-operative CT scans. Results indicated that brain volume increased significantly more in the EC group (100 ± 51 cm³) compared to the DC group (72 ± 51 cm³, p <
0.05). Both techniques effectively reduced midline displacement, but EC showed a superior capacity for brain expansion. The findings suggest that EC, which raises the cranial operculum to reduce soft tissue tension and provide hemostatic effects, may offer advantages over DC by allowing greater decompression and reducing the risk of complications such as epidural hematomas. These results support the potential of EC as a promising alternative to DC for treating intracranial hypertension. Future research should investigate long-term outcomes to further validate these findings.