Summary Summary:Normal to high cerebral perfusion pressure, normoxia, and surgical decompression are by far the most important and effective neuroprotective treatments in patients following severe head injury. Interventions to increase CBF in the ischemic terri-tory, reduction of cerebral metabolism, lactic acidosis and excitatory neurotransmitter activity,prevention of Ca++-influx, inhibition of lipidperoxidation, and free radical scavenging have been proposed to be protec-tive in cerebral ischemia. However, only few of these treatments have been proven to be efficacious in the setting of experimental or clinical head neurotrauma. With the current knowledge the following physical and pharmacological interventions seem to be justified in head injured patients: - Normoventilation (paCO2: 36 - 40 mmHg) in pa-tients with normal or moderately elevated ICP. Avoid prophylactic hyperventilation but transiently hyperventilate (paCO2: 30 - 34 mmHg) during epi-sodes of acute intracranial hypertension (plateau waves) until other interventions will reduce ICP. - In patients with head injury mild to moderate hypothermia cannot be recommended as a standard rather than an option when other treatment strategies fail to reduce ICP.In contrast,immediate and aggressive treatment of hyperthermia will reduce secondary injury. - Barbiturates may decrease elevated ICP and improve neurologic outcome. - Hyperglycemia is associated with worsened out-come following neurotrauma and plasma glucose concentrations should be assayed every 2 hours and maintained within the range of 100 - 150 mg/dl. - Patients suffering from head injury or traumatic subarachnoid hemorrhage do not benefit from the administration of nimodipine. - Rapid evacuation of epidural, subdural, or paren-chymal mass lesions is an effective and causal intervention in the treatment of secondary insults. Surgical decompression is currently ranked as a second tier treatment to avoid ischemic neuronal injury from sustained intracranial hypertension.