BACKGROUND: A comprehensive understanding of the spatial relationships between intracranial anatomy and pathological features is a crucial element in neurosurgical planning. OBJECT: To assess our clinical experiences using a novel approach, stereoscopic virtual reality environment, to help neurosurgeons with both surgical training and surgical strategic planning purposes. METHODS: Patient-specific digital imaging data obtained from a variety of different diagnostic sources (computed tomography, computed tomographic angiography, magnetic resonance, functional magnetic resonance, magnetic resonance-diffusion tensor imaging) were collected and then transferred to a workstation setting. These clinical data were obtained from 100 patients who were suffering from either brain vascular malformations or tumors that were located in difficult brain sites. A 3-dimensional volume rendering was produced for each of the 100 clinical cases, which were then subjected to data coregistration and fusion. RESULTS: By using different head positioning systems and craniotomy options, we simulated microscopic visualizations of the lesion through numerous surgical approaches and from various angles of view. This simulation strategy enabled us to carry out an approach selection and eventually to identify the optimum angle of lesion visualization. CONCLUSION: These virtual craniotomies successfully simulated a sampling of different operative environments that have the potential to play a significant role in neurosurgical training and operative planning worthy of further exploration and development.