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AIM To investigate clinical factors that may influence the decision to preserve or remove the bone flap during the craniectomy surgery for patients of traumatic brain injury. MATERIAL AND METHODS Clinical data from 2256 TBI patients were quantitatively analyzed and scored based on multiple clinical factors, including preoperative Glasgow Coma Scale (GCS) score, changes in pupil size, hematoma volume, time interval between injury and surgery, midline shift on CT scan, hematoma location and type, cortical collapse and the lateral ventricular shift deformation. RESULTS We identified several independent factors in the decision to preserve the bone flap: GCS score and pupil changes before the operation, cortical collapse, injury/surgery time interval and hematoma location. The results suggested that for patients with a combined score of ≥ 55, their bone flap was generally retained. For cases with a score of 50-55, the surgical decision was based on the patient level of preconscious status, changes in pupil size and the extent of postoperative cortical collapse, and for patients with a score < 50, the bone flap was generally removed. CONCLUSION Our scoring scheme is to identify factors that may be helpful when determining whether to remove or retain bone flap of TBI patients.