A recent randomized controlled trial in patients with ARDS showed the beneficial effect of mechanical ventilation according to the so called Open Lung Approach, consisting of low tidal volumes and elevated PEEP settings after performing recruiting maneuvers. However, neurosurgical patients were excluded from this and other ARDS trials due to concerns of intracranial deterioration. In this report, we present the clinical data of eleven patients with known intracranial pathology and concomitant ARDS which was treated according to the Open Lung concept. The mean oxygenation index (paO2/FiO2) increased from 132 +/- 88 to 325 +/- 64 measured 24 hours after initiation of Open Lung ventilation (p < 0.001). Mean PEEP level after the first recruiting maneuver was 14.9 +/- 3.2 mmHg. Comparison of mean and peak ICP values over 24 hours of time before and after the first recruitment maneuver revealed a non-significant decline in ICP despite a moderate increase in mean paCO2. Although two patients needed additional ICP treatment, no patient had to be withdrawn from Open Lung ventilation. In our series, Open Lung ventilation in neurosurgical patients with ARDS was a safe method to improve oxygenation. Careful ICP monitoring provided, there is no reason to withhold this modern ARDS treatment in the neurosurgical intensive care unit.