Neurosurgical intervention attempts to minimize secondary central nervous system injury after severe head injury through the evacuation of mass lesions with subsequent manipulation of cerebral perfusion pressure and intracranial pressure. The normal brain couples blood flow to metabolic demand through autoregulation of the cerebral vasculature. After severe head trauma and its attendant increase in intracranial pressure, marked alterations in cerebral blood flow and perfusion may occur. Currently, intervention is based on maintenance of coronary perfusion pressure and aggressive management of intracranial pressure. Both may be impacted by manipulation of ventilation, systemic blood pressure and volume status, administration of osmotic diuretics, and head elevation. Such therapy in the patient with severe head injury attempts to maintain coronary perfusion pressure and adequate oxygen delivery in a damaged central nervous system with altered hemodynamics and raised intracranial pressure.