Anesthetic management for neurosurgery in awake patients

Neurosurgery without general anesthesia is based on the necessity to avoid any interference between brain electrophysiological recordings and anesthetic agents, and the opportunity to have a patient able to follow commands and to cooperate during surgery. It includes not only several minimally invasive procedures, but also craniotomies for epilepsy surgery or the removal of tumors located close to brain eloquent areas. Before surgery, the patient must be carefully evaluated, correctly informed and appropriately prepared. In the operating room, monitoring is important for conducting the anesthetic management, ensuring patient's comfort and safety, and meeting surgical requests. Propofol and remifentanil are frequently used for anesthesia, but sufentanil, local anesthetics and a2-agonists are also of primary interest. Patient's ventilation may be spontaneous, assisted or controlled. Airway management is a key point strongly related to the anesthesia technique and the type of surgery. Airway may be secured with different airway devices and the laryngeal mask appears to progressively replace the endotracheal tube. Respiratory, hemodynamic, and neurologic complications as well as nausea and vomiting and loss of patient's cooperation may have disastrous consequences and should be prevented rather than cared.