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1. Neurological state of patientAssess. – ICP increase; size of ICP/CBF homeostatic reserve; intracranial compliance; autoregulation impairment; presence of neurological damage; present drug therapy.2. General state of patientCardiovascular system. – Brain perfusion/oxygenation depend on it; supratentorial surgery (meningiomas, metastasis) may result in significant bleeding.Respiratory system. – Hyperventilation to ↓ICP, CBF, CBV and brain tension depend on it.3. Anaesthetic strategyVascular access. – Consider risk of bleeding or venous air embolism, haemodynamic and metabolic monitoring, infusion needs for vasoactive and other substances.Fluid therapy—target. – Normovolemia/normotension, avoid hypoosmolar (Ringer’s lactate) and glucose-containing solutions.Anaesthetic regimen—“simple” procedures (low risk of ICP problems or ischemia, little need for brain relaxation). – Volatile-based technique; “high-risk” procedures (anticipated ICP problems, significant risk of intraoperative cerebral ischemia, need for excellent brain relaxation): use total intravenous anaesthesia.Extracranial monitoring. – For example, cardiovascular or renal, venous air embolism.Intracranial monitoring. – General environment vs. specific functions–metabolic (jugular venous bulb), neurophysiological (EEG/EP), functional (transcranial Doppler).4. Induction of anaesthesiaGoals. – Ventilatory control (early mild hyperventilation; avoid hypercapnia, hypoxemia); blood pressure control (avoid CNS arousal: adequate antinociception, anaesthesia); optimal position on ICP-volume curve.Patient positioning. – Pin holder application → maximal nociceptive stimulus, block by deeper anaesthesia or analgesia and local anesthetic pin site infiltration. Alternative: antihypertensives.5. Maintenance of anaesthesiaGoals. – Controlling brain tension via control of CMR and CBF: preventing CNS arousal (depth of anaesthesia, antinociception); treating consequences of CNS arousal (sympatholysis, antihypertensives); the “chemical brain retractor concept”.Neuroprotection. –Maintenance of an optimal intracranial environment (matching cerebral substrate demand and supply).6. Emergence from anaesthesiaGoals. – Maintain intra/extracranial homeostasis. Avoid factors → intracranial bleeding and/or ↑CBF/ICP. The patient should be calm, co-operative and responsive to verbal commands soon after emergence.Early vs. late emergence. – Ideal: rapid emergence to permit early assessment of surgical results and postoperative neurological follow-up, but there are still some categories of patients where early emergence is not appropriate. [Copyright &y& Elsevier]