Remimazolam Versus Propofol for Anesthesia in Intracranial Neurosurgeries: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Hemodynamic stability and timely neurological assessment are critical components of anesthetic management in intracranial neurosurgery. This systematic review and meta-analysis were prospectively registered in PROSPERO (CRD420251274560, registered December 28, 2025) and evaluated the efficacy and hemodynamic stability of remimazolam versus propofol as hypnotic agents in patients undergoing these procedures. PubMed, Embase, and Cochrane Library were searched for randomized controlled trials (RCTs) comparing remimazolam with propofol in patients undergoing intracranial neurosurgical procedures. The outcomes evaluated were heart rate (HR), mean arterial pressure (MAP), hypotension incidence, recovery characteristics, and adverse events. We computed mean difference (MD) or standardized mean difference (SMD) for continuous outcomes and risk ratio (RR) for binary outcomes, with 95% confidence intervals (CIs). Heterogeneity was assessed using I2 statistics. We included 7 RCTs, comprising 770 patients. Remimazolam was associated with a significantly shorter recovery time compared with propofol (MD: -1.74 min; 95% CI: -3.40 to -0.08; P=0.040; I2=48.7%). There were no significant differences between groups in anesthesia duration (MD: -3.31 min; 95% CI: -9.40 to 2.78; P=0.286; I2=0%), HR (MD: -1.79 bpm; 95% CI: -8.97 to 5.39; P=0.625; I2=97.5%), MAP (MD: -2.54 mm Hg; 95% CI: -6.09 to 1.00; P=0.160; I²=29.5%), and incidence of hypotension (RR: 0.56; 95% CI: 0.26-1.22; P=0.143; I2=72.4%). In conclusion, in patients undergoing intracranial neurosurgery, remimazolam use was associated with shorter recovery time and a hemodynamic profile similar to that of propofol.