Evaluation

• Detailed CN examination
  
• Computed tomography with 1-mm cuts and reconstruction in sagittal and coronal plane
  
  
  
  • Assess anatomic relationship between bone and lesion
    
  • Assess behavior of lesion with respect to bone (i.e., osteodestruction, hyperostosis, etc.)
  
  
• Magnetic resonance imaging with and without gadolinium
  
  
  
  • Assess soft tissue characteristics, including lesion, brain, vessels, CNs
  
  
• Magnetic resonance angiography/magnetic resonance venography if indicated for vertebral artery involvement/dominance, sinus dominance/patency, jugular bulb anatomy
  
• Consider cerebral angiography for embolization of vascular lesions, assessment of arteriovenous anatomy in region of lesion

• Headlight/loupes
  
• Mayfield head clamp
  
• High-speed drill
  
• Microscope
  
• Neurophysiologic monitoring: somatosensory evoked potential, motor evoked potentials, brain stem auditory evoked responses, pharyngeal leads, tongue/facial electromyographies
  
• Facial nerve stimulator (Kartush)
  
• Ultrasonic aspirator
  
• Consider lumbar drain for postoperative control of cerebrospinal fluid (CSF)

Operating Room Set-up

• Anesthesia apparatus should be placed at the foot of the table.

Anesthetic Issues

• Allow for neurophysiologic monitoring
  
• Arterial line
  
• Central venous access
  
• Sequential compression devices (SCDs)/thromboembolism deterrent stockings (TEDS)
  
• Dexamethasone 10 mg intravenous (IV) for intradural lesions
  
• Mannitol 0.5 to 1 g/kg IV bolus for intradural lesions
  
• Antibiotics
  
• Normocapnia