Positioning

• Use radiolucent Mayfield skull clamp if intraoperative angiography is planned
  
• Patient is supine with head fixation using double Mayfield skull pin sites positioned low at ipsilateral retromastoid region and single pin in sagittal plane of contralateral midpupillary line just behind the hairline if possible
  
• Turn head away from side of craniotomy and extend neck so that malar eminence is at highest point of operative field to allow gravity to facilitate brain retraction
  
• Neck should be positioned to avoid excessive compression of jugular veins and the endotracheal tube
  
  
  
  • Elevation of the head of bed and ipsilateral shoulder elevation with a shoulder roll are used to ensure adequate jugular venous return

Planning of Incision and Shave