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The anesthetic management of complex skull base surgical procedures provides unique problems and concerns for the neuroanesthesiologist. Positioning to access the skull base could put the patient at risk for peripheral nerve injury and some of the positions may increase the risk for air emboli. In addition, tumor pathology and involvement with vital structures could increase the chances for substantive blood loss, destruction of associated nerves or vessels, and may require temporary occlusion of the carotid artery necessitating intraoperative neuroprotection. Neurophysiological monitors may also be used to safeguard nerve function and anesthetic techniques must be adjusted to accommodate their use. Finally, postoperative morbidity may be affected by surgical approach to the skull base and the anesthesiologist should be aware of which approach may produce a greater incidence of pain, nausea, and vomiting in the postoperative period. The authors discuss the anesthetic concerns and management for complex cranial base surgery. Different approaches will be discussed and comparisons of perioperative parameters between these approaches will be made with data provided by retrospective chart review of more than 600 skull base procedures performed at the authors' institution over the last 10 years. This information should help guide decision making concerning anesthetic management for these skull base procedures.

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