The risk of morbidity/mortality exists with any surgical/ anaesthetic procedure, but the risk to the central nervous system may be compounded in a patient undergoing a major neurosurgical procedure. The purpose of the pre-operative assessment includes the identification of modifiable risk factors, optimization of the patient's condition, explanation of the risks and formulating the best possible anaesthetic plan for the patient. The general physical examination should focus on the patient's level of consciousness, degree of neurological impairment, mental status, nutrition and vital parameters for baseline. Focused neurological assessment and careful documentation allow the establishment of baseline status and facilitate anaesthetic planning, as well as anticipation of potential perioperative complications. The risk of perioperative respiratory complications is increased in the presence of pre-existing obstructive or restrictive pulmonary disease. Patients at risk of aspiration include those with full stomachs, delayed gastric emptying, bowel obstruction, and gastro-oesophageal reflux.