The use of magnetic resonance imaging (MRI) for the real time guidance of surgical procedures is now undergoing clinical trials. Among the many procedures explored, open craniotomy neurosurgery appears to be among the most promising. Over 50 such cases have been done at the Brigham and Women's Hospital (BWH) in Boston. We review the technical approach used in these and related procedures. We consider the way in which imaging is used to augment and improve the procedures. As well, the implications of these protocols for remote diagnosis and telesurgery are explored. Finally, the implications of this experience for the insertion of new technology into medicine are discussed.