Airway management in neurosurgical patients presents unique challenges to the anaesthetist. This review will consider specific approaches to numerous problems in airway management related to logistical, physiological and anatomical concerns. The goal is to provide a clinically oriented and practical discussion regarding issues of airway management in neurosurgical patients.The recent literature has been reviewed regarding airway management options and related perioperative complications in the neurosurgical population. This is interlaced with approaches to many of the problems and their solutions based on experience gained in a very busy university neurosurgical practice over the past decade.Specific pathophysiological alterations in the neurosurgical patient influence the technique chosen for securing an airway. These relate to the presence of increased intracranial pressure, intracranial aneurysms or arteriovenous malformations. Other important disorders influencing airway management include severe coronary artery disease, acromegaly and congenital airway difficulties. Stereotactic neurosurgery and conscious sedation for various neurosurgical procedures also provide unique challenges. There are other considerations unique to the neurosurgical patient such as intra-and postoperative airway obstruction and the timing of postoperative extubation.The demands for airway management in neuroanaesthesia require expertise in the various modes of securing the airway while considering the patient's physiological requirements as well as the unique surgical demands.