Increased intracranial pressure in patients with acute liver failure (ALF) remains a major immediate cause of mortality. Several studies in animal models of ALF set the stage for the clinical application of moderate hypothermia in man. Studies in patients with ALF and increased intracranial hypertension have shown that temperatures as low as 32 degrees C are safe and effectively reduce increased intracranial pressure unresponsive to other medical therapies, and can be used as a successful bridge to liver transplantation. Data from studies in patients undergoing liver transplantation for ALF suggest that increases in intracranial pressure can be prevented during the dissection and reperfusion phases of the operation if the patients are maintained hypothermic during surgery. The present review focuses upon the clinical aspects of using hypothermia as a treatment of increased intracranial pressure in patients with ALF.