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Patents will require imaging on the day of the procedure. They may have a CT scan, an MRI scan, or angiography. Alternatively, they may have a combination of the different types of imaging. Very specific sequences for imaging are required for Gamma Knife patients. The patients will receive intravenous contrast for the imaging that is required. Patients having MRI scans will receive gadolinium. Patients having CT scans will have an iodine-based dye. Patients having an angiogram also receive an iodine-based contrast. It is very important to assess the patient for any gadolinium or iodine dye contrast allergies prior to the day of treatment. If a patient has a known contrast dye allergy they will require premedication prior to receiving the contrast. The premedication will be a combination of steroids and Bena­dryl and must begin 13 h prior to administration of the contrast medium.

Ativan is given to most patients preoperatively as a mild sedative. It is long acting so it will help the patient relax during the planning stage of the procedure as well as the treatment. Intravenous fentanyl and Versed is used for intraoperative sedation during the frame application. Patients tend to be very anxious anticipating the frame application. Small doses of fentanyl and Versed provide a mild conscious sedation during the frame application. We typically use 50 µg of fentanyl and 1 mg of Versed prior to frame placement. Sedation dosages will be adjusted for each patient. A topical numbing agent, Emla cream, is applied to the patient’s forehead upon arrival. The cream, lidocaine 2.5% and prilocaine 2.5%, will start the numbing process on the forehead. A mixture of lidocaine 5% and Marcaine 5% is injected into the four pin sites, two on the forehead and two on the back of the head. Some medications to keep on hand for occasional use include atropine in the event of a vagal response, hydralazine in the event a patient becomes hypertensive, and Zofran in the event a patient becomes nauseated. Postoperatively, patients may be given Solu-Medrol prophylactically to prevent swelling. We encourage patients to take Tylenol following the procedure to help with any headache they may experience once the head frame is removed. Table 1 provides a list of medications that we commonly use.

Table 1. Commonly used medications