Effect of Remimazolam and Propofol on Intraoperative Blood Pressure Variability in Patients Undergoing Endovascular Embolization of Intracranial Aneurysms

Background: Maintaining stable arterial blood pressure during endovascular embolization of intracranial aneurysms is of great importance due to impaired cerebrovascular autoregulation and the risk of ischemic or hemorrhagic complications. Intraoperative blood pressure variability has been associated with adverse postoperative outcomes. This study aimed to compare the effects of remimazolam and propofol on intraoperative arterial blood pressure variability during endovascular embolization of intracranial aneurysms. Methods: A prospective randomized controlled trial with blinded patients and outcome assessors was conducted in 63 patients undergoing endovascular embolization of intracranial aneurysms. Patients were randomly assigned to receive either remimazolam or propofol for general anesthesia. Mean arterial pressure (MAP) was recorded at 5-minute intervals. The primary outcome was intraoperative blood pressure variability, quantified by the average real variability (ARV) of MAP. Secondary outcomes included additional indices of blood pressure variability (standard deviation [SD], coefficient of variation [CV], and MAP range), intraoperative hypotension, norepinephrine use, and postoperative clinical outcomes. Results: MAP-ARV was significantly lower in the remimazolam group than in the propofol group ( P < 0.001). Similarly, MAP-SD, MAP-CV, and MAP range were all reduced in the remimazolam group ( P < 0.001). The incidence of hypotension was lower in the remimazolam group (31.3% vs 71.0%, P = 0.002), with fewer hypotensive episodes, shorter duration of hypotension, and reduced norepinephrine use ( P < 0.05). Surgeon satisfaction was higher in the remimazolam group ( P = 0.015). No significant differences were observed in postoperative neurological outcomes, complications, or length of hospital stay. Conclusion: 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. However, no significant differences were observed in postoperative neurological or functional outcomes between the two groups. Keywords: arterial blood pressure variability, hemodynamics, remimazolam, propofol, endovascular embolization of intracranial aneurysms