Room Setup

You will need a Layla bar. 

Medications

• 10mg dexamethasone
• 20mg Lasix
• 50g mannitol
• 1g Keppra
• 2g Ancef

Monitoring

• SSEPs
• 8-channel EEG
• No motors

Pinning

• Radiolucent Mayfield
• Double pins on the occiput in the axial plane
• Single pin at the intersection of the hairline and superior temporal line on the side contralateral to the pathology

Positioning

Body:

• Table is turned 90 degrees
• Place a bump under the ipsilateral shoulder
• Tuck the arm
• Leave the ipsilateral groin exposed in case of intraoperative angio

Head: 

• Thrust the head forward, towards the ceiling
• Turn 20 degrees to the side contralateral to the pathology
• Drop the vertex of the head and extend the neck. This facilitates frontal lobe retraction with gravity. 

Incision

Curvilinear incision behind the hairline extending from 1 cm anterior to the tragus of the ipsilateral ear to a few cm past midline. 

Infiltrate the incision with local. 

Approach

Skin Incision

Make incision with a skin blade then take the Bovie down to the bone. Raise a single myocutaneous flap. Dissect the temporalis away from the bone with a Penfield 1 or Love-Adson. Don't elevate it from the bone with the Bovie. 

Secure to the Layla bar with fish hooks. 

Craniotomy

Use the perforator to make three burr holes at the keyhole, bottom of the exposure (near but not quite at the root of the zygoma), and posteriorly. Be sure to extend the craniotomy frontally to expose a significant amount of frontal lobe. 

The only departure from the below picture is that he does not use Raney clips. 

Dissect the dura away from the inner table of the skull with a Woodson then Penfield 3. 

Turn the crani with a B1. 

Dura

Open the dura in a single curvilinear incision from top to bottom. The dural incision is similar to the skin incision but starts more anteriorly. I.e. give yourself a healthy ~1 inch margin from the posterior border of the crani.