Over the past two decades there has been an approximately 20% absolute reduction in the mortality associated with severe traumatic brain injury (TBI). This dramatic improvement has not received much attention, mostly because there is no single intervention that can be credited for this. In fact, so far no pharmacological agent has been proven to be effective in Phase III clinical trials of acute TBI. Nevertheless, there are several organizational, physiological, and surgical measures, that when used in concert, have resulted in a dramatic improvement in mortality. Perhaps even more importantly, the quality of survival has been enhanced. In this talk, the current thinking on the clinical management of TBI will be reviewed, along with the lessons learned from recent pharmacological trials.