Epilepsy is a complex disease that imposes great disability on those affected. Epilepsy surgery is an underutilized treatment option and an awake craniotomy is sometimes warranted to allow precise cortical mapping. This chapter presents a case study of a 20-year-old healthy male with a history of seizure disorder who was found to have a right frontal brain tumor. The primary concerns of the anesthesiology team were: (1) management of intraoperative pain, particularly during Mayfield cranial pin placement, (2) management of the airway, (3) the potential for nausea and vomiting, and (4) intraoperative seizures during cortical stimulation. The patient was brought to the operating room and brief sedation was induced using a propofol and alfentanil infusion. There are several pitfalls for which anesthesiologists should be aware, close monitoring, team communication, the safe and judicious use of long-acting local analgesia and prompt management of intraoperative seizures make for safe perioperative care.