Awake craniotomy enables intraoperative assessment of a patient's neurological status. It is most commonly performed for the resection of tumours within eloquent cortex and it is now considered a standard of care. Other indications include epilepsy surgery and neuromodulation for the treatment of Parkinson's disease, tremor, dystonia, and other intractable movement disorders.

Paradoxically, providing anaesthesia for an ‘awake’ procedure, presents particular challenges for the anaesthetist. Although safe and well tolerated, complications occur which can be reduced by meticulous planning and good communication. An understanding of the stages of the surgical procedure and their unique anaesthetic requirements is required. Various anaesthetic techniques are described but there is no one optimal technique. Each case requires individual planning with regards to most suitable technique. Many drugs can be used to deliver sedation, analgesia, or anaesthesia, each requiring finesse with dosing and titration. Effective local anaesthesia is essential no matter what technique is chosen. Awake craniotomies are rewarding cases, with clear benefits in terms of improved patient outcomes and reduction in hospital stay and costs.