BACKGROUND: Lasting bilateral mydriasis and absence of pupillary light reflex following severe traumatic brain injury (TBI) are considered signs of irreversible brainstem damage and have been strongly associated with poor outcome.CASE DESCRIPTION: A young female patient presented with severe TBI, contusions, and diffuse brain edema. She was initially treated medically, but developed delayed secondary refractory intracranial hypertension and bilaterally dilated, non-reactive pupils for 12 h. Wide decompressive craniectomy and dural incisions were performed. The patient presented gradual improvement in her clinical condition [Glasgow Coma Scale (GCS) 13/15]. Delayed recurring infections lead to the patient's death due to sepsis after 3 months.CONCLUSION: In light of recent studies, lasting bilateral mydriasis may not always be considered a decisive factor for non-escalation of treatment, as variability among TBI patients and outcomes has been demonstrated. Wide decompressive craniectomy is viable for controlling refractory intracranial hypertension in hemodynamically stable patients.