A primary focus throughout the perioperative course for patients undergoing a decompressive craniectomy is to reduce the risk of secondary brain injury and improve patient outcomes. In addition to the standard goals of maintaining oxygenation, adequate perfusion, and hemodynamic stability, the physiologic goals during this emergency surgery are specific to this patient population. This article reviews the overall intraoperative management goals and unique considerations during key portions of the perioperative course, including preoperative evaluation, vascular access, induction and maintenance of anesthesia, fluid balance, and transfusion goals.