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Background: This multi-centre study aimed to describe indications and outcomes in spontaneous supratentorial intracerebral haemorrhage (ICH) patients treated with decompressive craniectomy (DC).

Methods: All patients undergoing DC for spontaneous ICH at five Swedish neurosurgical centres between 2008 and 2022 were included (n = 45). Clinical, radiological, and outcome data were extracted. Outcome at six months was assessed using the modified Rankin Scale (mRS), dichotomized as favourable vs. unfavourable (mRS 0–3 vs. 4–6), and survival vs. mortality (mRS 0–5 vs. 6).

Results: Based on estimated ICH incidence, DC was performed in approximately 1.5 per 1000 cases. Median age was 47 years and the median ICH volume was 51 mL. Eighty-nine percent underwent ICH evacuation. DC performed as a primary procedure without ICP monitoring in 33%, whereas 67% underwent secondary DC due to refractory ICP elevation. Preoperative midline shift (median 11 mm) and basal cistern compression (present in 96%) significantly improved postoperatively (p < 0.001). Reoperation occurred in <10%. At follow-up, 28% were deceased and 40% had recovered favourably.

Conclusions: DC performed in a highly selected ICH population resulted in significant mass effect reduction and a relatively high rate of favourable outcome. Patient selection remains crucial but challenging, and larger prospective studies are warranted.