Operative Planning

• Review imaging (magnetic resonance imaging preferred)
  
• Magnetic resonance angiography or angiography helpful for venous anatomy
  
• Avoid increased intracranial pressure (ICP) at surgery; consider ventriculos-tomy or ventricular drain for hydrocephalus, or preoperative third ventriculostomy if indicated
  
• If significant lateral or supratentorial component, may need other approach
  
• If lesion displaces deep cerebral venous complex inferiorly, may need supratentorial approach
  
• Lesions extending inferiorly or arising in the quadrigeminal plate may require an occipital-transtentorial approach

Equipment

• Major craniotomy tray
  
• Long bayonet “pineal” instruments
  
• Mayfield head holder
  
• High-speed drill
  
• Yasargil bar and Greenberg retractors
  
• Armrest

Operating Room Set-up

• Headlight
  
• Loupes
  
• Bipolar cautery and Bovie cautery
  
• Microscope (variable focal length preferred)

Anesthetic Issues