Remimazolam in neurosurgery

Purpose of review Remimazolam represents a novel intravenous anesthetic agent whose use began in 2020. As a new ultrashort-acting benzodiazepine, it has unique pharmacokinetic properties, such as remifentanil, designed to be active and easily transformed into inactive metabolites by tissue esterases. The purpose is to search the literature and evidences to use this new medication in neurosurgery. Recent findings Currently, it is allowed for procedural sedation and general anesthesia in a few countries. More advantages of this new drug are predictable onset, short duration, rapid recovery profile, low liability for respiratory depression, cardiovascular depression, lack of injection pain, and known reversible agent, flumazenil. A literature search led to the conclusions that remimazolam may maintain better hemodynamic stability and reduce the episodes of hypotension during coil embolization of cerebral aneurysm and that general anesthesia with remimazolam does not alter cerebral metabolism, cerebral blood flow, and cerebral blood volume. Also, because it facilitates safe and quick arousal, it can be a suitable medication for awake craniotomy. Summary With more desirable properties such as reduced risk of prolonged sedation and reliable safety margin, it is expected to increase the safety of sedation and general anesthesia in future.