BACKGROUND: Scarce resource allocation in traumatic brain injury (TBI) care is ethically challenging. We surveyed neurosurgeons about their views on surgical decision-making in TBI in resource-limited settings. METHODS: Neurosurgeons and trainees completed an online survey about surgical decision-making for TBI when neurosurgical capacity is limited. The survey included questions about the impact of patient-level factors (such as the patient's need for surgery or potential for improvement in mortality) and system-level factors (such as operating theater and bed space availability) on decision-making, as well as the perceived fairness of several resource allocation principles when applied to TBI surgery. RESULTS: The 63 respondents were from low- and/or middle-income countries (27%) and high-income countries (73%, n = 46). Most neurosurgeons (61%, n = 35/57) reported the patient's need for surgery as the primary patient-level driver of decision-making, and operating room space was the main system-level factor (71%, n = 35/49). Neurosurgeons generally thought sickest-first and prognosis were the fairest resource allocation principles. CONCLUSIONS: Respondents generally prioritized their patients' need for surgery, projected benefits, and system considerations such as operating theater capacity in their decision to operate. Respondents prioritized both the sickest patients and those with the best prognosis in the setting of limited surgical capacity. Future research should explore how to work towards an agreed-upon framework for decision-making in resource-scarce settings in a just and equitable way.