Acute subdural haematoma is a well-entrenched nosological entity implying subdural collection of blood following acute head injury. Pathologically, it is usually associated with or, for that matter, secondary to cerebral contusion and laceration. Based on cumulated experience, clinical and pathological studies it is proposed that, for too long the neurosurgeons have put emphasis on the clot rather than the totality of the pathological anatomy and that they have focused their therapeutic strategy on removal of the accumulated blood, unmindful of the associated parenchymatous lesion. Not surprisingly, such attempts have been associated with a very high mortality. On the basis of nearly four decades of personal experience and critical review of the literature, evidence has been provided that to reduce the mortality associated with this condition, it is necessary to evolve a strategy, not only to evacuate the blood but comprehensively deal with the associated parenchymatous lesions and the cascade of secondary insult to the underlying brain.