Prenatal myelomeningocele has rapidly become the most common in-utero surgery performed following the results of the multi-center, myelomeningocele study. In-utero surgery has greatly improved the prognosis of babies with spina bifida or myelomeningocele. The eligibility criteria for this surgery has also evolved as some centers are now operating on mothers with increased body mass index (BMI). A BMI greater than 40 was not incorporated into the original study. In addition, fetoscopic repair of the myelomeningocele is also being performed, allowing for a decrease in the risk for uterine dehiscence and also offering mothers the opportunity to have a vaginal delivery following in-utero surgery.

Among medical therapies, osmotherapy with colloidal agents (mannitol, glycerol) or crystalloid agents (hypertonic saline) is reasonable for patients whose condition is deteriorating due to mass effect and herniation from large anterior circulation hemispheric or cerebellar infarcts, especially as bridging therapies to definitive surgical intervention. Hyperventilation and hypothermia may also be reasonable, though are of less certain benefit. Corticosteroids have not been found helpful. Agents that block sulfonylurea receptor-mediated cellular swelling, such as intravenous glyburide, have shown promise but require pivotal trial testing. Ventriculostomy is useful to treat non-communicating hydrocephalus arising from obstruction of CSF flow pathways by swollen brain infarcts. But in select large cerebellar infarcts, ventricular drainage alone may exacerbate upward herniation of swollen cerebellar tissues, and suboccipital craniectomy along with ventricular drainage is preferred. Suboccipital craniectomy, often with resection of infarcted tissue, is recommended for massive cerebellar infarcts that may herniate directly into the brainstem, on the basis of observational evidence. Hemicraniectomy for brain oedema associated with large anterior circulation hemispheric infarction is life-saving, but survivors often have severe disability, especially when over age 60. If pursued, hemicraniectomy is generally best performed within 48 h of onset and before development of advanced herniation and neurological deterioration.

Acute non-traumatic intracerebral haemorrhage (ICH) has a poor prognosis and is the least treatable form of acute stroke.Although less common than acute ischaemic stroke, ICH causes greater premature loss of productive life years on a global scale due to its predilection to affect people at younger ages with devastating consequences.Prognosis from ICH is related to location, initial volume and speed of expansion of the haematoma, and associated intraventricular haemorrhage. Care in a specialised stroke or neurointensive care unit improves outcome. Surgical haematoma evacuation should be pursued as for patients with cerebellar haemorrhage with neurologic deterioration, hydrocephalus, orsd brainstem compression. Haematoma evacuation may be considered, as a life-saving measure, in patients with coma or large haematoma with mass effect.Minimally-invasive surgery in stable patients is of uncertain benefit and is being evaluated in RCTs.Clinicians should not routinely use haemostatic therapies where there is no evidence of coagulopathy or anticoagulant use.When coagulopathy is present, early corrective measures should be taken. Early moderate intensity BP lowering to a systolic BP target of 140 mmHg is reasonable.Medical therapies to reduce mass effect and intracranial pressure should not be used routinely, but hyperventilation and hypertonic saline or colloidal osmotic agents are reasonable in patients with imminent herniation as a bridge to definitive neurosurgical intervention. Corticosteroids should be avoided.Novel neuroprotective approaches hold promise.