This review summarizes the current anesthetic management of patients undergoing craniotomies in the awake state.As the practice of neurosurgery has moved towards less invasive procedures the need for prolonged, deep general anesthesia has decreased. Since brain mapping and neurophysiologic testing is an integral part of many neurosurgical techniques, the need to provide sufficient analgesia and sedation without interference with electrophysiologic monitoring is also essential.A safe and acceptable analgesic/amnestic state for these procedures can be provided by the use of dexmedetomidine, with or without the addition of remifentanil.