The morbidity and mortality of herpes simplex encephalitis have decreased since the 1980s with the use of antivirals, but have remained stable in the last couple of years. One cause of morbidity is the development of focal hemorrhagic necrosis and edema in the temporal lobe, giving rise to space-occupying lesions, with a subsequent elevation of intracranial pressure. In some cases, the necrosis and edema can be refractory to medical treatment, with fatal outcome. Under these circumstances, some authors proposed decompressive craniectomy to treat severe intracranial hypertension and prevent serious neurologic deficits. We report the clinical outcomes of 2 adolescents affected with herpes simplex encephalitis who developed, during the course of their illness, severe intracranial hypertension refractory to medical treatment. Decompressive surgery was undertaken, with good outcomes in both patients.