Background: Head injury remains one of the most common causes of death worldwide. Approximately 10 to 50% of patients with head injury developed disability at some point in their illness, and represent one of the most common brain casualty encountered by neurosurgeons. Objective: This study was aimed to assess and evaluate a group of patients with open head injury including depressed skull fracture and skull fractures associated with epidural hematoma, subdural hematoma, intracerebral hematoma or foreign body penetration regarding surgical management and post-operative results. Patients and methods: The study was done prospectively in the Neurosurgery Department, Al-Azhar University Hospitals and Matareya Teaching Hospital; the study included 30 patients with acute open traumatic head injury requiring surgical intervention in the form of Decompressive. Craniotomy with evacuation of hematomas if existed or elevation of depressed skull fractured bones. Results: In this study, depressed fracture was present in 17 cases, fissure fracture in 7 cases, skull base fracture in 2 cases, diastatic fracture in 1 case and beveling (bullet inlet and exit) in 1case. Also, in this study, 9 cases (30%) had Glasgow Outcome Score I (GOS I), 3 cases (10%) had GOS III, 3 cases (10%) had GOS IV and 15 cases (50%) had GOS V. Regarding the overall complications, chest infections were detected in 4 cases, frontal manifestations in 1 case, grade 4 Lt. sided weakness in 1 case, stable GCS at 14 in 2 cases, reoperation in 1 case and right hemiparesis in 1 case. Conclusion: It could be concluded that surgical intervention is the ideal solution for the management of acute traumatic brain injury (TBI) with persistent increased ICP when the other medical management fail under the good circumstances of early intervention and the other factors.