Comparative investigation of the incidence of intraoperative seizures with propofol and remimazolam during anesthetic management for awake craniotomy: Retrospective propensity score matching study

Seizures are serious complications of awake craniotomy (AC), and generalized clonic seizures are problematic because they require pharmacologic termination and emergency airway management. Although associations between seizure onset and anesthetic agents such as propofol and dexmedetomidine have been reported, data on remimazolam are limited. This study aimed to investigate the characteristics of seizures in patients undergoing AC and to compare the frequency of intraoperative seizures associated with propofol and remimazolam administration for anesthetic management. The data of 328 patients who underwent AC at our hospital until September 2024 were retrospectively reviewed. They were divided into propofol (group P, n = 259) and remimazolam (group R, n = 69) groups. To ensure comparable baseline characteristics, propensity score matching was performed. After propensity score matching, 49 patients were selected from each group (Group R, n = 49; Group P, n = 49). Fifty-eight patients (17.6%) experienced seizures during AC. No significant difference in the frequency of seizures was observed between the groups anesthetized with propofol (Group P: 46 events) and remimazolam (Group R: 14 events; P = .37). Forty-nine patients were selected from each group after propensity score matching. The difference in the incidence of seizures was not significant (10 and 13 events in Groups P and R, respectively; P = 1.00). Binary logistic regression analysis revealed no association between seizure occurrence and anesthetic management with remimazolam (P = .18). However, younger patients were more likely to experience seizures during AC (odds ratio, 0.95; 95% confidence interval, 0.935-0.983; P < .01). The similar frequencies of seizures associated with the use of remimazolam and propofol suggest that remimazolam might not increase the risk of intraoperative seizures during AC. These findings indicate that remimazolam may be safely used as an anesthetic for AC.