Comparative Evaluation of Total Intravenous and Inhalational Anesthesia in Posterior Fossa Surgery

Background and Objectives: Posterior fossa surgery presents unique anesthetic challenges owing to restricted intracranial compliance, proximity to vital brainstem structures, and the need for optimal brain relaxation and smooth emergence for early neurological assessment. Total intravenous anesthesia (TIVA) and inhalational anesthesia are commonly employed techniques in neuroanesthesia, yet comparative evidence in posterior fossa surgery remains limited. This study aimed to compare TIVA with inhalational anesthesia in terms of hemodynamic stability, intracranial pressure (ICP), brain relaxation, surgeon satisfaction, and perioperative outcomes in posterior fossa surgery. Materials and Methods: This prospective, randomized, comparative study was conducted at the Pacific Institute of Medical Sciences, Udaipur, between October 2024 and September 2025. Sixty adult patients (ASA physical status I–II) undergoing elective posterior fossa surgery in the park bench position were randomized into two groups: Group T (TIVA with propofol and dexmedetomidine infusion) and Group I (inhalational anesthesia with sevoflurane). Direct ICP monitoring was employed intraoperatively. Hemodynamic parameters, ICP trends, brain relaxation scores, and surgeon satisfaction scores were recorded. Secondary outcomes included emergence time, incidence of coughing or bucking during extubation, postoperative nausea and vomiting (PONV), and duration of postoperative ICU ventilation. Results: Demographic characteristics and surgical duration were comparable between the two groups. Hemodynamic parameters and ICP trends remained stable in both groups, with lower intraoperative ICP values observed in the TIVA group. Brain relaxation scores and surgeon satisfaction were significantly higher in the TIVA group. Emergence time was slightly prolonged with TIVA, while the incidence of PONV and coughing during extubation was significantly lower. Duration of postoperative ICU ventilation was comparable between groups. Conclusion: Both TIVA and sevoflurane-based inhalational anesthesia provide safe and effective anesthetic conditions for posterior fossa surgery. TIVA offers advantages of better control of ICP, superior brain relaxation, higher surgeon satisfaction, and reduced PONV, making it a valuable anesthetic technique in posterior fossa neurosurgery.