Remimazolam or Propofol for Brain Vascular Surgery: What Happens to Delirium?
Remimazolam keeps coming up in our journals, and for good reason. It is a short acting benzodiazepine that tends to hold blood pressure better than propofol, and it can be reversed with flumazenil. The worry that always follows is delirium, since benzodiazepines have a poor reputation in older and sicker patients. A trial published October 29, 2026 in the British Journal of Anaesthesia looked at that question in neurovascular surgery.
The study
The team at Samsung Medical Center in Seoul ran a single center, double blind, randomized noninferiority trial in adults having elective aneurysm clipping, arteriovenous malformation resection, microvascular decompression, or STA to MCA bypass. These are cases where neuromonitoring usually rules out much volatile anesthetic, so total intravenous anesthesia is the norm. Patients got either remimazolam based TIVA with flumazenil at emergence or propofol based TIVA, both with remifentanil.
Delirium was checked twice a day for five days with CAM-ICU or 3D-CAM. In 686 patients, it occurred in 12.8% of the remimazolam group and 10.8% of the propofol group, a difference of about 2 percentage points (95% CI -2.85 to 6.80). That met the preset noninferiority margin of 10 points. Remimazolam patients had much less time below a MAP of 65 (median 0 versus 7.5 mm Hg minutes), and more of them were extubated in the operating room (85.2% versus 67.3%).
How I read it
This is reassuring, with one honest caveat that the authors raise themselves. Delirium was less common than they expected when they set the margin, and a 10 point margin is wide when the baseline rate is around 11%. So I would say remimazolam did not cause a large increase in delirium here, but the trial cannot rule out a small one. The point estimate leaned slightly toward propofol.
The hemodynamic and extubation findings are the part I find most useful. Less hypotension and more patients waking up and breathing on their own at the end of a long brain case are real advantages, both for the patient and for getting an early neurologic exam.
What it means for practice here
We do not do a high volume of this kind of neurosurgery in Casper, but the lesson carries over to any long TIVA case in a patient who does not tolerate drops in pressure well. Remimazolam looks like a reasonable option when hemodynamic stability matters, as long as we stay alert for delirium, screen for it after surgery, and keep in mind that this was one center with fairly healthy elective patients. I would want to see similar results in older and frailer groups before treating it as a routine swap for propofol.
Source
- Kim J, Lee S, Bang YJ, et al. Effect of remimazolam versus propofol anaesthesia on postoperative delirium in neurovascular surgery: a randomised noninferiority trial. British Journal of Anaesthesia. Published online October 29, 2026. PMID 42957499. Abstract (PubMed)
- ClinicalTrials.gov registration NCT06115031. Trial record
This post is clinician commentary for educational discussion. It is not medical advice for any reader's personal care. Anesthesia and perioperative decisions should be made with the treating clinician based on the individual patient's circumstances.