Despite extensive research, the prognosis for patients with severe traumatic brain injury (TBI) remains poor. TBI is the leading cause of mortality and morbidity in young adults worldwide, so it is also a major health and socioeconomic problem. The most important factor determining prognosis is the severity of the primary brain injury, but if the primary injury leads to delayed secondary brain damage, this also combines to determine outcome. A key strategy in TBI treatment should, therefore, be surgical management of the injury and intensive care to prevent additional secondary brain injury. To achieve optimal and seamless care for patients with TBI, clinicians need an adequate understanding of the pathophysiology and mechanisms of TBI, and a universal strategy for its treatment must be established. This paper focuses on the pathophysiological basis of primary and secondary brain injuries, and discusses the indications for surgical treatment in each type of TBI.