Comparison of Propofol and Inhalational Anaesthetics for Brain Relaxation in Neurosurgery: A Network Meta-Analysis

Abstract

Background: In neurosurgery, relaxation of the brain is a key factor in surgical exposure and outcome in the case of intracranial surgery. The theoretical advantages and disadvantages of total intravenous anaesthesia (TIVA) (propofol) and volatile inhalational agents (sevoflurane, isoflurane, desflurane) are both present and absent with the available evidence split over dozens of small, heterogeneous randomized controlled trials (RCTs).
A current (2022-2026) review of the literature that compares the pros and cons of propofol and inhalational anaesthetic for brain relaxation and related peri-operative outcomes in neurosurgery, integrating the existing network of pairwise and multiple treatment meta-analytic evidence.
Methods: A systematic literature search (Scopus, PubMed/MEDLINE, Cochrane Library, Embase) was performed from January 2022 to
July 2026, which compared propofol to sevoflurane, isoflurane or desflurane in adult patients undergoing craniotomy or other intra-cranial neurosurgical procedures within RCTs, cohort studies and meta-analyses. Intraoperative brain relaxation score, ICP, haemodynamic stability, emergence and recovery times, postoperative nausea and vomiting (PONV), postoperative cognitive dysfunction (POCD)/delirium, biomarkers of neuronal injury and mortality/morbidity were extracted from the data. Findings were presented in a narrative synthesis and combined with previously published pairwise and network meta-analyses to create a network of treatments between propofol, sevoflurane, isoflurane and desflurane as per the general principles of the PRISMA-NMA reporting framework.
Results: Sixteen primary studies and meta-analyses were included, including RCTs, retrospective and nationwide cohort studies, and systematic reviews in a number of thousands of patients. In most head to head trials and meta analyses, scores for brain relaxation were equally comparable between propofol and volatile agents. Propofol-based anaesthesia was associated with a modestly lower risk of intraoperative brain swelling (risk ratio [RR] 0.85), lower ICP (mean difference [MD] approximately −4 mmHg), less tachycardia (RR 0.54) and less PONV compared with volatile anaesthesia in pooled meta-analytic data. For recovery, desflurane was the fastest emerging/extubating of the inhalational agents but in at least one study was associated with more PONV and more tachycardia than TIVA. There was inconsistent evidence for postoperative cognitive dysfunction and delirium; a large multicentre randomised controlled trial (RCT) and a global observational cohort study produced partially opposing results. There was no significant difference in 90-day death rates among large national cohort data for patients undergoing cranial neurosurgery, although a small effect favoring TIVA was seen on similar spine-surgery data.
Conclusion: Both propofol and volatile inhalational agents have similar effects on brain relaxation during surgery, but propofol has slight benefits for ICP control, haemodynamic stability and for PONV, and desflurane has the best recovery times of the volatile agents across the current evidence network. There is no clear and consistent benefit for either technique regarding long-term neurologic outcomes and death.
Until the results of larger and well powered individual patient data network meta-analysis, selection of the anaesthetic should be individualised, and based on patient comorbidities, monitoring needs and institutional experience..