Introduction & Objective: Reducing mortality and disability are the main objectives of cranial decompression in patients with malignant intracranial hypertension. Hinge craniotomy (HC) is an alternative technique to decompressive craniectomy (DC), this study is designed to compare efficacy of these 2 procedures in the management of patients with malignant intracranial hypertension. Materials & Methods: Prospective, randomized, controlled trial including 38 adult patients undergoing cranial decompression who were randomly assigned to a decompressive craniectomy (n=19) or hinge craniotomy group (n=19). Postoperative variables such as ‘Intracranial pressure (ICP) therapeutic index’, duration of mechanical ventilation, duration of the admission in Intensive Care Unit (ICU), length of hospital stay were assessed. Radiographic outcomes were assessed by comparing preoperative and postoperative Computed Tomography (CT) scans. Postoperative complications such as infection, need for reoperation due to the lack of ICP control, wound healing problems, bone infection, etc. were recorded. Functional neurologic outcome was monitored by using the Modified Rankin Scale and Glasgow Outcome Scale in 3, 6, and 12 months after operation. Results: There was no significant difference in preoperative demographic variables between the two groups. The mean duration of mechanical ventilation, ICU admission, and hospital stay was 29±26.27, 32.79±26.30, and 47.16±27.28 days in the DC group and 24.21±30.21, 27.84±30, and 38.53±35.41 days in the HC group which showed no significant difference. There was no significant difference in the preoperative brain CT analysis between two groups. The mean Rotterdam score was 4.53±0.84 and 4.58±0.6 in the DC and HC group respectively, indicating no significant difference. The ratio of the largest craniotomy diameter to the largest anterior-posterior diameter of the skull was 0.76±0.05 in the DC and 0.76±0.04 in the HC group. The brain expansion percentage was 10.22% in DC and 8.69% in HC patients without a significant difference. Conclusions: It seems that HC can be a suitable alternative to the DC because of less complications rate and similar short-term and long-term outcome. By performing HC, a major surgery (cranioplasty) is reduced and the financial burden is removed from the patient and the health system.