Abstract: Objective To investigate the impact of tracheostomy timing on in-hospital prognosis in neurosurgical patients admitted to the Intensive Care Unit (ICU) after cranial surgery. Methods A retrospective cohort study was conducted, including 188 patients who underwent tracheostomy after cranial surgery in the ICU of Beijing Tiantan Hospital, Capital Medical University, between July 2023 and July 2024. Based on the time from endotracheal intubation to tracheostomy, patients were divided into an early tracheostomy group (≤7 days) and a late tracheostomy group (>7 days). Baseline data and clinical outcomes were collected and compared between the two groups. Univariate and multivariate analyses were used to evaluate factors influencing tracheostomy timing and the impact of early tracheostomy on in-hospital prognosis. Results A total of 188 patients were included, with 49 in the early tracheostomy group and 139 in the late tracheostomy group. Multivariate analysis showed that postoperative brain tumor patients, impaired cough reflex, and the occurrence of ventilator-associated pneumonia were independent factors influencing tracheostomy timing (P < 0.05). Early tracheostomy was an independent factor associated with reduced hospitalization costs, shorter duration of mechanical ventilation, and shorter ICU and total hospital stays (P < 0.05). Conclusion For neurosurgical patients after cranial surgery, particularly those with brain tumors and impaired cough reflex, early tracheostomy (≤7 days) can effectively reduce the incidence of ventilator-associated pneumonia, shorten the duration of mechanical ventilation and hospitalization, and significantly decrease medical costs.