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Abstract Introduction Heuristics are mental shortcuts that reduce effort in decision-making under uncertainty. Patients often use these strategies to simplify surgical information, yet their role in consent and outcomes is poorly understood. This study aims to quantify heuristic use in neurosurgical patients and examine associations with decisional conflict and self-reported outcomes. Methods We conducted a cross-sectional study in patients undergoing endoscopic transsphenoidal surgery at a tertiary neurosciences centre. Patients completed a heuristic questionnaire, the Decisional Conflict Scale (DCS), and free-text on postoperative symptoms. Both instruments used 5-point Likert scales, where higher scores indicated greater heuristic reliance or decisional certainty. Associations with DCS were tested using Spearman’s rank correlation, outcome differences with Kruskal–Wallis, and free-text thematically analysed. Results Eighteen patients were included. The authority heuristic was most common, with patients often relying on clinician advice when deciding on surgery (mean 4.3/5). The least used were familiarity and social proof, where decisions were based on personal or others’ prior experiences (2.6/5). Mean DCS was 4.5/5, consistent with low decisional conflict, with no significant correlations between heuristics and DCS (P > 0.2). Thematic analysis defined three self-reported outcome groups: improved (n = 9, 50%), persistent (n = 6, 33%), and worsened or new (n = 3, 17%). Anchoring, giving weight to the first information received, differed significantly between groups (χ² = 6.35, P = 0.042), being higher among those with persistent or worsened symptoms. Conclusions This study provides the first evidence that heuristics shape patient decision-making in neurosurgery. Recognising these cognitive shortcuts may enhance consent, improve shared decision-making, and reduce decisional regret.