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Background: Evidence suggests that liberal transfusion and anemia correction have negative effects on patients with acute brain injuries (ABI). Such patients with indications for decompressive surgeries require precise and real-time monitoring technology for estimation of intraoperative hemoglobin in order to assess the need for transfusion. Aims: The primary objective was to evaluate non-invasive hemoglobin (SpHb) monitoring as a guide for red blood cell transfusion (RBCT) during emergency decompressive craniotomy in ABI patients. The secondary objectives were to evaluate the incidence of postoperative infections, length of ICU stay, duration of mechanical ventilation, 30-day mortality, and extended Glasgow outcome scale (E-GOS) score at 90 days. Methods and Material: Eighty patients (aged 18-65) with ABI requiring decompressive surgery were randomized into two groups of 40 patients each: group A (SpHb monitoring group) and group B (standard care group). They were compared for RBCT management, and postoperative infections, ventilator days, length of stay in ICU, E-GOS, and mortality. RESULTS: The number of patients requiring a single RBCT was significantly higher in group A as compared to Group B (P < 0.0001). However, patients requiring two transfusions and the total volume of RBCT were higher in group B (P < 0.01). Three or more RBCT were required only in Group B (P 0.07). The duration of mechanical ventilation was higher in group B as opposed to group A (P 0.07). However, there was no significant difference in the hemodynamic variables between the two groups. Conclusions: The inclusion of continuous SpHb monitoring during decompressive procedures in ABI patients may assist in the optimal management of blood transfusion, thereby reducing transfusion-related complications.