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Most of the intracranial aneurysms and vascular lesions(arteriovenous malformations, dural arteriovenous fistulas (dAVFs), and cavernous malformations) can be safely accessed either endovascularly or through open microscopic approaches with excellent outcomes. However, for those that are not well suited to endovascular treatment, there are regions of the ventral skull base best accessed endonasally and there are certain vascular lesions of the proximal anterior and posterior circulation with specific characteristics—be it location, size, and in cases of aneurysms, aneurysm projection, and neck features—for which open transcranial approaches can be a Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, PUH B-400,