The patient had application of the external fiducial markers and was brought down to the MRI suite where a head MRI was obtained using the frameless stereotactic (3D) protocol. The image set was transferred using the DICOM protocol over the hospital Ethernet to the intraoperative workstation and a three dimensional reconstruction of the head and target was created.

The patient was transported to the operating room and after adequete general endotracheal anestesia was achieved was carefully positioned in pins in the Mayfield headholder with padding of the extremities in the usual fashion.

The external fiducial markers were identified with the OTS for the initial stereotactic localization and using surface matching technique the median error was reduced to 1.0 mm. A craniotomy incision was marked using 3D planning and the operative site was prepped and draped in the standard sterile fashion.

The incision was created with a #10 blade and taken down the to pericranium. Bipolar electrocautery was employed. A cerebellar self retaining retractor was placed. The pericranium was elevated using a periosteal elevator. A single burr hole was created with the Codman performator and the bone edges were waxed. The #3 Penfield was used to strip the dura under the bone flap and a craniotomy was performed with the Midas Rex craniotome. The dura was tacked to the skull edges using several 4-0 Neurolon sutures in the usual fashion. The dura was opened in a cruxiate fashion. The Budde Halo self retaining retractor system was attached.

The tumor was highly vascular and cystic.

The tumor was removed with the cavitron, bipolar electrocautery and suction.The frozen section pathology revealed:Malignant astrocytoma

After meticulous hemostasis with bipolar electrocautery the systolic blood pressure was elevated to 160mm Hg and the operative bed was examined with continued excellent hemostasis. The systolic blood pressure was then lowered and maintained at less than 140 mm Hg for 24 hours. The operative bed was lined with surgicel and again copiously irrigated with lactated Ringer's solution. The dura mater was reapproximated with interrupted and running 4-0 Neurolon sutures and the closure was lined with surgicel. The bone flap was reattached using stainless steel wires in the usual fashion. The incision was irrigated with antibiotic solution and the galea was reapproximated with inverted 3-0 Vicryl sutures in an interrupted fashion. Stainless steel surgical staples were used to reapproximate the scalp edges and a dry sterile dressing was applied. The patient was returned to the supine position, extubated and transferred to the SICU in excellent condition.