Effect of remimazolam versus propofol anaesthesia on postoperative delirium in neurovascular surgery: a randomised noninferiority trial.

Summary

In 686 patients undergoing elective neurovascular surgery, postoperative delirium occurred in 12.8% of patients receiving remimazolam and 10.8% receiving propofol. Remimazolam met the prespecified noninferiority criterion for delirium and produced a lower hypotensive burden and higher operating-room extubation rate.

Key Findings

• Postoperative delirium occurred in 12.8% of the remimazolam group and 10.8% of the propofol group.
• Remimazolam was noninferior to propofol for postoperative delirium using a 10-percentage-point noninferiority margin.
• Hypotensive burden below a mean arterial pressure of 65 mm Hg was lower with remimazolam, and operating-room extubation was more frequent.

Clinical Implications

Remimazolam-based total intravenous anesthesia may be considered when rapid emergence, reduced hypotension, or operating-room extubation is desirable, provided that delirium risk is monitored and local experience with flumazenil reversal is adequate.

Limitations

• The study was conducted at a single centre, which may limit generalizability to other neuroanesthetic practices.
• The observed delirium incidence was lower than anticipated when the noninferiority margin was defined.

Future Directions

Multicenter pragmatic trials should assess remimazolam across broader neurosurgical populations, evaluate longer-term cognitive outcomes, and examine cost-effectiveness and optimal flumazenil strategies.