Effect of Remimazolam and Propofol on Intraoperative Blood Pressure Variability in Patients Undergoing Endovascular Embolization of Intracranial Aneurysms.
Duan Y, He J, et al. • Drug design, development and therapy • 2026
In patients undergoing endovascular embolization of intracranial aneurysms, remimazolam was associated with reduced intraoperative arterial blood pressure variability and improved hemodynamic stability compared with propofol, though no significant differences were observed in postoperative neurological or functional outcomes between the two groups.
Key Findings
Results
Remimazolam produced significantly lower intraoperative blood pressure variability than propofol as measured by average real variability of mean arterial pressure.
The primary outcome was intraoperative blood pressure variability quantified by the average real variability (ARV) of MAP, recorded at 5-minute intervals.
MAP-ARV was significantly lower in the remimazolam group than in the propofol group (P < 0.001).
63 patients undergoing endovascular embolization of intracranial aneurysms were enrolled in this prospective randomized controlled trial.
The trial used blinded patients and outcome assessors.
Results
All secondary blood pressure variability indices were significantly reduced in the remimazolam group compared to the propofol group.
MAP standard deviation (MAP-SD), coefficient of variation (MAP-CV), and MAP range were all reduced in the remimazolam group.
All three secondary variability measures reached statistical significance at P < 0.001.
These measures represent distinct approaches to quantifying hemodynamic instability during anesthesia.
Results
The incidence of intraoperative hypotension was substantially lower in the remimazolam group than in the propofol group.
Incidence of hypotension was 31.3% in the remimazolam group versus 71.0% in the propofol group (P = 0.002).
The remimazolam group also had fewer hypotensive episodes and shorter duration of hypotension (P < 0.05).
Norepinephrine use was reduced in the remimazolam group (P < 0.05).
Maintaining stable blood pressure during these procedures is of great importance due to impaired cerebrovascular autoregulation and the risk of ischemic or hemorrhagic complications.
Results
Surgeon satisfaction was significantly higher in the remimazolam group than in the propofol group.
Surgeon satisfaction was higher in the remimazolam group (P = 0.015).
This outcome was assessed as a secondary endpoint in the trial.
Results
No significant differences in postoperative neurological outcomes, complications, or length of hospital stay were observed between the two groups.
Postoperative neurological outcomes did not differ significantly between the remimazolam and propofol groups.
Postoperative complications and length of hospital stay were also not significantly different between groups.
The lack of difference in clinical outcomes occurred despite the significant improvements in intraoperative hemodynamic stability with remimazolam.
The study was a prospective randomized controlled trial with 63 patients, which may limit statistical power to detect differences in less common clinical outcomes.
What This Means
This research suggests that the anesthetic drug remimazolam keeps blood pressure more stable during a delicate brain procedure — endovascular embolization, which is used to treat brain aneurysms — compared to the commonly used anesthetic propofol. In a study of 63 patients, those given remimazolam experienced far less fluctuation in their blood pressure during surgery. They also had roughly half the rate of dangerously low blood pressure episodes (31% versus 71%), needed less medication to correct low blood pressure, and their surgeons reported greater satisfaction with the operating conditions.
Despite these clear advantages in blood pressure stability during surgery, the two drugs produced similar outcomes after the operation. There were no meaningful differences between the groups in neurological recovery, complications, or how long patients stayed in the hospital. This is an important finding because stable blood pressure during brain aneurysm surgery is considered critical — swings in pressure can potentially cause bleeding or reduced blood flow to the brain — yet whether better intraoperative control translates to better recovery remains an open question based on this study's sample size.
This research suggests that remimazolam may be a preferable option to propofol for anesthesia during intracranial aneurysm procedures, particularly for patients where blood pressure stability is a concern. However, the study was relatively small and did not find improvements in patient outcomes after surgery, so larger studies would be needed to determine whether the improved hemodynamic stability with remimazolam ultimately leads to better long-term patient recovery.
Duan Y, He J, Han C, Yang W, Wang Z, Zhou X, et al.. (2026). Effect of Remimazolam and Propofol on Intraoperative Blood Pressure Variability in Patients Undergoing Endovascular Embolization of Intracranial Aneurysms.. Drug design, development and therapy. https://doi.org/10.2147/DDDT.S630786