 Traumatic brain injury, TBI, remains a leading cause of death from trauma, accounting for approximately one-third of all trauma-related deaths over the last four decades. Despite significant progress in understanding the pathophysiology of TBI, its treatment remains challenging due to the complex nature of the injury. Early recognition and prompt intervention are essential for achieving better outcomes. Surgeons must be aware of the controversies surrounding the management of severe TBI, STBI, including the following, mode of pre-hospital transportation, maintenance of airway patency while securing the cervical spine, achieving adequate ventilation, optimizing circulatory physiology, fluid resuscitation and blood product transfusions, antiplotlet and anticoagulant reversal strategies, and emergency surgical interventions. Recent advances in the field include the use of tranhexamic acid, which may improve outcomes in STBI.