J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

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Review

Volume 17, Number 3, March 2025, pages 125-135

Clinical Experience With Remimazolam in Neuroanesthesiology and Neurocritical Care: An Educational Focused Review

**Table 1.** Reports of Remimazolam Administration for Procedural Sedation During Neuroimaging and Related Procedures
Author and reference	Demographic and surgical/imaging procedure	Dosing and outcome
CT: computed tomography; MRI: magnetic resonance imaging.
Hirano et al [14]	Cohort of 48 children with median age of 7 years for CT, MRI, angiography, and radiation therapy	Remimazolam administered as a continuous infusion (12 mg/kg/h) and decreased to 1 - 2 mg/kg/h once the desired level of sedation was achieved (Ramsay sedation score of 3). Bolus doses (0.2 mg/kg) were administered as needed to sustain the desired sedation level. Adjunctive agents (ketamine, fentanyl, or propofol) were used in 95% of the patients. None of the patients required pharmacological intervention to manage hemodynamic changes. The authors concluded that remimazolam, when supplemented with propofol or ketamine, was a safe and effective agent for procedural sedation.
Villalobos et al [15]	A 9-month-old, 8.72 kg toddler for MRI. Comorbid conditions included viral infection (COVID), high fever, and seizure.	Remimazolam titrated from 15 to 20 µg/kg/min without a bolus dose. Two supplemental doses of dexmedetomidine (4 µg). Successful completion of MRI with a native airway, spontaneous ventilation, and no respiratory concerns.
Yeh et al [16]	Case series of a 19-year-old, 47.3 kg patient undergoing CT imaging and a 16-year-old, 64.1 kg patient for halo removal	Patient 1 received four individual bolus doses of remimazolam (2.5 mg each) without adjunctive agents. Adequate sedation achieved with a native airway and spontaneous ventilation. Brief episode of hypotension and one episode of apnea, both of which resolved without intervention. Second patient received initial bolus of 5 mg followed by three additional doses of 2.5 mg. Single dose of fentanyl (50 µg fentanyl). Adequate sedation with spontaneous ventilation and a native airway.

Table 1. Reports of Remimazolam Administration for Procedural Sedation During Neuroimaging and Related Procedures

Author and reference

Demographic and surgical/imaging procedure

Dosing and outcome

CT: computed tomography; MRI: magnetic resonance imaging.

Hirano et al [14]

Cohort of 48 children with median age of 7 years for CT, MRI, angiography, and radiation therapy

Remimazolam administered as a continuous infusion (12 mg/kg/h) and decreased to 1 - 2 mg/kg/h once the desired level of sedation was achieved (Ramsay sedation score of 3). Bolus doses (0.2 mg/kg) were administered as needed to sustain the desired sedation level. Adjunctive agents (ketamine, fentanyl, or propofol) were used in 95% of the patients. None of the patients required pharmacological intervention to manage hemodynamic changes. The authors concluded that remimazolam, when supplemented with propofol or ketamine, was a safe and effective agent for procedural sedation.

Villalobos et al [15]

A 9-month-old, 8.72 kg toddler for MRI. Comorbid conditions included viral infection (COVID), high fever, and seizure.

Remimazolam titrated from 15 to 20 µg/kg/min without a bolus dose. Two supplemental doses of dexmedetomidine (4 µg). Successful completion of MRI with a native airway, spontaneous ventilation, and no respiratory concerns.

Yeh et al [16]

Case series of a 19-year-old, 47.3 kg patient undergoing CT imaging and a 16-year-old, 64.1 kg patient for halo removal

Patient 1 received four individual bolus doses of remimazolam (2.5 mg each) without adjunctive agents. Adequate sedation achieved with a native airway and spontaneous ventilation. Brief episode of hypotension and one episode of apnea, both of which resolved without intervention. Second patient received initial bolus of 5 mg followed by three additional doses of 2.5 mg. Single dose of fentanyl (50 µg fentanyl). Adequate sedation with spontaneous ventilation and a native airway.

**Table 2.** Reports of Remimazolam for Awake Craniotomy in Adult Patients
Author and reference	Demographic and surgical procedure	Remimazolam dosing and outcome
LMA: laryngeal mask airway.
Sato et al [20]	A 37-year-old, 58 kg man for awake craniotomy and tumor resection	Induction with remimazolam (12 mg/kg/h), remifentanil (0.1 µg/kg/min), and fentanyl (75 µg) followed by rocuronium (20 mg) and LMA placement. Anesthesia maintained with remimazolam (1 mg/kg/h) and remifentanil (0.12 - 0.15 µg/kg/min). Twenty-six minutes after discontinuation of medications, the patient was fully awake and cooperative for language mapping. No adverse effects noted.
Murata et al [21]	A 45-year-old, 39 kg woman for awake craniotomy and tumor resection	Induction with remimazolam (4 mg) over 1 min and remifentanil infusion (1 µg/kg/min) followed by rocuronium (20 mg) and LMA placement. Anesthesia was maintained with remimazolam (1.0 - 1.2 mg/kg/h, then reduced to 0.1 µg/kg/min for last 5 min before discontinuation) and remifentanil (0.1 - 0.3 ug/kg/h). Flumazenil (0.05 mg) to speed recovery for language mapping. No adverse effects.
Yoshida et al [22]	A 48-year-old man for awake craniotomy and tumor resection	Induction with remimazolam (6 mg/kg/h) and remifentanil (100 µg) followed by LMA placement. Anesthesia maintained with remimazolam (0.75 - 1 mg/kg/h) and remifentanil (0.1 µg/kg/min). Following discontinuation of remimazolam and flumazenil bolus (0.3 mg), the patient awoke 3 min later and was able to follow commands.
Sato et al [23]	A 78-year-old, 47.2 kg woman for awake craniotomy and tumor resection	Induction with remimazolam (12 mg/kg/h) and remifentanil (0.15 µg/kg/min) followed by rocuronium (20 mg) and LMA placement. Anesthesia maintained with remimazolam (0.3 - 0.7 mg/kg/h). Remimazolam discontinued and flumazenil (0.5 mg) administered for awake phase. Patient was able to perform language tasks with no adverse effects.
Sato et al [24]	Two male patients, 44 and 54 years of age, weighing 98.4 and 90.7 kg, for awake craniotomy for tumor resection	Induction with remimazolam (12 mg/kg/h) and remifentanil (0.1 - 0.15 µg/kg/min) followed by LMA placement. Anesthesia maintained with remimazolam (0.5 - 0.6 mg/kg/h) and remifentanil (0.1 - 0.15 µg/kg/min). Following discontinuation of both agents, one patient received flumazenil (0.5 mg). Both patients awoke and performed intraoperative tasks without adverse effects.

Table 2. Reports of Remimazolam for Awake Craniotomy in Adult Patients

Author and reference

Demographic and surgical procedure

Remimazolam dosing and outcome

LMA: laryngeal mask airway.

Sato et al [20]

A 37-year-old, 58 kg man for awake craniotomy and tumor resection

Induction with remimazolam (12 mg/kg/h), remifentanil (0.1 µg/kg/min), and fentanyl (75 µg) followed by rocuronium (20 mg) and LMA placement. Anesthesia maintained with remimazolam (1 mg/kg/h) and remifentanil (0.12 - 0.15 µg/kg/min). Twenty-six minutes after discontinuation of medications, the patient was fully awake and cooperative for language mapping. No adverse effects noted.

Murata et al [21]

A 45-year-old, 39 kg woman for awake craniotomy and tumor resection

Induction with remimazolam (4 mg) over 1 min and remifentanil infusion (1 µg/kg/min) followed by rocuronium (20 mg) and LMA placement. Anesthesia was maintained with remimazolam (1.0 - 1.2 mg/kg/h, then reduced to 0.1 µg/kg/min for last 5 min before discontinuation) and remifentanil (0.1 - 0.3 ug/kg/h). Flumazenil (0.05 mg) to speed recovery for language mapping. No adverse effects.

Yoshida et al [22]

A 48-year-old man for awake craniotomy and tumor resection

Induction with remimazolam (6 mg/kg/h) and remifentanil (100 µg) followed by LMA placement. Anesthesia maintained with remimazolam (0.75 - 1 mg/kg/h) and remifentanil (0.1 µg/kg/min). Following discontinuation of remimazolam and flumazenil bolus (0.3 mg), the patient awoke 3 min later and was able to follow commands.

Sato et al [23]

A 78-year-old, 47.2 kg woman for awake craniotomy and tumor resection

Induction with remimazolam (12 mg/kg/h) and remifentanil (0.15 µg/kg/min) followed by rocuronium (20 mg) and LMA placement. Anesthesia maintained with remimazolam (0.3 - 0.7 mg/kg/h). Remimazolam discontinued and flumazenil (0.5 mg) administered for awake phase. Patient was able to perform language tasks with no adverse effects.

Sato et al [24]

Two male patients, 44 and 54 years of age, weighing 98.4 and 90.7 kg, for awake craniotomy for tumor resection

Induction with remimazolam (12 mg/kg/h) and remifentanil (0.1 - 0.15 µg/kg/min) followed by LMA placement. Anesthesia maintained with remimazolam (0.5 - 0.6 mg/kg/h) and remifentanil (0.1 - 0.15 µg/kg/min). Following discontinuation of both agents, one patient received flumazenil (0.5 mg). Both patients awoke and performed intraoperative tasks without adverse effects.

**Table 3.** Remimazolam During Intraoperative Neuromonitoring in Pediatric and Adult Patients
Author and reference	Demographic and surgical procedure	Remimazolam dosing and outcome
MEP: motor evoked potential; NMBA: neuromuscular blocking agent; SSEP: somatosensory evoked potential; TIVA: total intravenous anesthesia; VEP: visual evoked potential.
Tanaka et al [28]	Cohort of nine adult patients, 63 ± 9 years of age, undergoing aneurysm clipping, carotid endarterectomy, and tumor resection	VEPs and SSEPs during TIVA with remifentanil and either remimazolam (0.8 to 1.0 mg/kg/h) or propofol (4 - 6 mg/kg/h). VEPs were higher with remimazolam while SSEPs were comparable between remimazolam and propofol.
Kondo et al [29]	Two patients of 76 and 70 years age undergoing laminoplasty for cervical spondylotic myelopathy and anterior cervical discectomy and fusion with intraoperative MEP monitoring	Induction with remimazolam (6 or 12 mg/kg/h) with remifentanil (0.3 µg/kg/min). Following NMBA and tracheal intubation, anesthesia maintained with remimazolam (0.5 - 1.5 mg/kg/h) and remifentanil (0.2 - 0.5 µg/kg/min). Successful intraoperative MEP monitoring with no significant changes compared to preoperative baseline.
Arashiro et al [30]	A 17-year-old, 64.5 kg woman with Alstrom syndrome for posterior spinal fusion for functional scoliosis. Alstrom syndrome is a rare genetic disorder with dilated cardiomyopathy, liver dysfunction, and scoliosis.	Inhalation induction followed by maintenance of anesthesia with remimazolam (0.5 - 1 mg/kg/h) and remifentanil (0.3 µg/kg/min). Posterior spinal fusion and successful MEP monitoring.
Kamata et al [31]	A 12-year-old, 55 kg adolescent with egg hypersensitivity for craniotomy with direct cortical MEP monitoring	Induction with remimazolam at 6 mg/kg/h and maintenance of anesthesia with remimazolam (1.5 mg/kg/h) and remifentanil (0.5 µg/kg/min). Successful MEP monitoring.
Hughes et al [32]	Cohort of 40 adolescents with mean age of 15.3 years old undergoing posterior spinal fusion	Remimazolam started at 2.5 - 10 µg/kg/min (median 5 µg/kg/min) with maintenance doses at a median of 8 µg/kg/min added to baseline anesthesia with either desflurane, propofol, or dexmedetomidine/ketamine. This was combined with an opioid infusion (sufentanil or remifentanil). Successful neurophysiological monitoring (MEP and SSEP). Remimazolam decreased requirements for volatile agent or propofol requirements by at least 15-30%.
Aoki et al [33]	A 57-year-old woman for open repair of a thoracic descending aortic aneurysm	Induction with remimazolam (12 mg/kg/h). Maintenance of anesthesia with remimazolam (0.2 - 1 mg/kg/h) and remifentanil. No significant changes in MEP with remimazolam administration.

Table 3. Remimazolam During Intraoperative Neuromonitoring in Pediatric and Adult Patients

Author and reference

Demographic and surgical procedure

Remimazolam dosing and outcome

MEP: motor evoked potential; NMBA: neuromuscular blocking agent; SSEP: somatosensory evoked potential; TIVA: total intravenous anesthesia; VEP: visual evoked potential.

Tanaka et al [28]

Cohort of nine adult patients, 63 ± 9 years of age, undergoing aneurysm clipping, carotid endarterectomy, and tumor resection

VEPs and SSEPs during TIVA with remifentanil and either remimazolam (0.8 to 1.0 mg/kg/h) or propofol (4 - 6 mg/kg/h). VEPs were higher with remimazolam while SSEPs were comparable between remimazolam and propofol.

Kondo et al [29]

Two patients of 76 and 70 years age undergoing laminoplasty for cervical spondylotic myelopathy and anterior cervical discectomy and fusion with intraoperative MEP monitoring

Induction with remimazolam (6 or 12 mg/kg/h) with remifentanil (0.3 µg/kg/min). Following NMBA and tracheal intubation, anesthesia maintained with remimazolam (0.5 - 1.5 mg/kg/h) and remifentanil (0.2 - 0.5 µg/kg/min). Successful intraoperative MEP monitoring with no significant changes compared to preoperative baseline.

Arashiro et al [30]

A 17-year-old, 64.5 kg woman with Alstrom syndrome for posterior spinal fusion for functional scoliosis. Alstrom syndrome is a rare genetic disorder with dilated cardiomyopathy, liver dysfunction, and scoliosis.

Inhalation induction followed by maintenance of anesthesia with remimazolam (0.5 - 1 mg/kg/h) and remifentanil (0.3 µg/kg/min). Posterior spinal fusion and successful MEP monitoring.

Kamata et al [31]

A 12-year-old, 55 kg adolescent with egg hypersensitivity for craniotomy with direct cortical MEP monitoring

Induction with remimazolam at 6 mg/kg/h and maintenance of anesthesia with remimazolam (1.5 mg/kg/h) and remifentanil (0.5 µg/kg/min). Successful MEP monitoring.

Hughes et al [32]

Cohort of 40 adolescents with mean age of 15.3 years old undergoing posterior spinal fusion

Remimazolam started at 2.5 - 10 µg/kg/min (median 5 µg/kg/min) with maintenance doses at a median of 8 µg/kg/min added to baseline anesthesia with either desflurane, propofol, or dexmedetomidine/ketamine. This was combined with an opioid infusion (sufentanil or remifentanil). Successful neurophysiological monitoring (MEP and SSEP). Remimazolam decreased requirements for volatile agent or propofol requirements by at least 15-30%.

Aoki et al [33]

A 57-year-old woman for open repair of a thoracic descending aortic aneurysm

Induction with remimazolam (12 mg/kg/h). Maintenance of anesthesia with remimazolam (0.2 - 1 mg/kg/h) and remifentanil. No significant changes in MEP with remimazolam administration.

**Table 4.** Remimazolam in Patients With Comorbid Conditions
Author and reference	Demographic data and surgical procedure	Comorbid condition	Remimazolam dosing
DMD: Duchenne muscular dystrophy; ERCP: endoscopic retrograde cholangiopancreatography; MELAS: mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes; MH: malignant hyperthermia.
Ogino et al [36]	A 21-month-old, 8.7 kg infant undergoing gastrostomy placement	Immune-mediated necrotizing myopathy	Induction with remimazolam (10 mg/kg/h) and fentanyl (3 µg/kg). NM blockade - rocuronium. Maintenance of anesthesia with remimazolam (1 - 2 mg/kg/h) and intermittent fentanyl.
Horikoshi et al [37]	A 4-year-old, 16 kg toddler undergoing inguinal herniorrhaphy	DMD	Remimazolam (15 mg/hr or 15-16 µg/kg/min) and remifentanil infusion, intermittent fentanyl. NM blockade - rocuronium.
Fukuda et al [38]	A 58-year-old, 68 kg woman undergoing ERCP	Myotonic dystrophy type 1	Induction with remimazolam (12 mg/kg/h) and remifentanil (0.1 µg/kg/min). NM blockade - rocuronium. Maintenance of anesthesia with remimazolam (0.8 - 1.0 mg/kg/h) and remifentanil (0.1 µg/kg/min).
Morimoto et al [39]	A 46-year-old, 60 kg man undergoing phacoemulsification and intraocular lens implantation	Myotonic dystrophy type 1	Induction with remimazolam (6 mg/kg/h). NM blockade. Maintenance of anesthesia with remimazolam (0.25 - 0.5 mg/kg/h) and remifentanil (0.2 µg/kg/min).
Morita et al [40]	A 16-year-old, 23 kg adolescent undergoing intrathecal baclofen pump exchange	Stiff person syndrome	Induction with remimazolam (4 mg) and remifentanil (0.5 µg/kg/min). NM blockade - rocuronium. Maintenance of anesthesia with remimazolam (2 mg/kg/h) and remifentanil (0.1 - 0.3 µg/kg/min). Depth of anesthesia monitored with the BIS.
Yamadori et al [41]	A 10-year-old girl undergoing open gastrostomy	MELAS syndrome	Induction with remimazolam (0.2 mg/kg bolus). NM blockade. Maintenance of anesthesia with remimazolam (1 - 2 mg/kg/h) and remifentanil (0.1 - 0.25 µg/kg/min).
Gyurgyik et al [42]	A 12-year-old, 52.6 kg adolescent undergoing right eye muscle surgery	MELAS syndrome	Maintenance of anesthesia with dexmedetomidine (0.5 µg/kg/min), remifentanil (0.3 - 0.4 µg/kg/min), and remimazolam (5 - 10 µg/kg/min). NM blockade - rocuronium. Depth of anesthesia monitored with the BIS.
Petkus et al [43]	A 6-year-old, 24.3 kg girl undergoing dental rehabilitation	Family history of MH	Induction with propofol. Maintenance of anesthesia with remimazolam (5 - 7 µg/kg/min) and propofol (50 µg/kg/min). Analgesia with morphine and ketorolac.
Kiyokawa et al [44]	A 5-year-old boy undergoing inguinal herniorrhaphy	Medium chain acyl dehydrogenase deficiency	Induction with remimazolam (4 mg bolus). Maintenance of anesthesia with remimazolam (2 mg/kg/h) and remifentanil (0.5 µg/kg/min). NM blockade - rocuronium. Depth of anesthesia monitored with the BIS. Rectus sheath and ilioinguinal nerve blockade.

Table 4. Remimazolam in Patients With Comorbid Conditions

Author and reference

Demographic data and surgical procedure

Comorbid condition

Remimazolam dosing

DMD: Duchenne muscular dystrophy; ERCP: endoscopic retrograde cholangiopancreatography; MELAS: mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes; MH: malignant hyperthermia.

Ogino et al [36]

A 21-month-old, 8.7 kg infant undergoing gastrostomy placement

Immune-mediated necrotizing myopathy

Induction with remimazolam (10 mg/kg/h) and fentanyl (3 µg/kg). NM blockade - rocuronium. Maintenance of anesthesia with remimazolam (1 - 2 mg/kg/h) and intermittent fentanyl.

Horikoshi et al [37]

A 4-year-old, 16 kg toddler undergoing inguinal herniorrhaphy

DMD

Remimazolam (15 mg/hr or 15-16 µg/kg/min) and remifentanil infusion, intermittent fentanyl. NM blockade - rocuronium.

Fukuda et al [38]

A 58-year-old, 68 kg woman undergoing ERCP

Myotonic dystrophy type 1

Induction with remimazolam (12 mg/kg/h) and remifentanil (0.1 µg/kg/min). NM blockade - rocuronium. Maintenance of anesthesia with remimazolam (0.8 - 1.0 mg/kg/h) and remifentanil (0.1 µg/kg/min).

Morimoto et al [39]

A 46-year-old, 60 kg man undergoing phacoemulsification and intraocular lens implantation

Myotonic dystrophy type 1

Induction with remimazolam (6 mg/kg/h). NM blockade. Maintenance of anesthesia with remimazolam (0.25 - 0.5 mg/kg/h) and remifentanil (0.2 µg/kg/min).

Morita et al [40]

A 16-year-old, 23 kg adolescent undergoing intrathecal baclofen pump exchange

Stiff person syndrome

Induction with remimazolam (4 mg) and remifentanil (0.5 µg/kg/min). NM blockade - rocuronium. Maintenance of anesthesia with remimazolam (2 mg/kg/h) and remifentanil (0.1 - 0.3 µg/kg/min). Depth of anesthesia monitored with the BIS.

Yamadori et al [41]

A 10-year-old girl undergoing open gastrostomy

MELAS syndrome

Induction with remimazolam (0.2 mg/kg bolus). NM blockade. Maintenance of anesthesia with remimazolam (1 - 2 mg/kg/h) and remifentanil (0.1 - 0.25 µg/kg/min).

Gyurgyik et al [42]

A 12-year-old, 52.6 kg adolescent undergoing right eye muscle surgery

MELAS syndrome

Maintenance of anesthesia with dexmedetomidine (0.5 µg/kg/min), remifentanil (0.3 - 0.4 µg/kg/min), and remimazolam (5 - 10 µg/kg/min). NM blockade - rocuronium. Depth of anesthesia monitored with the BIS.

Petkus et al [43]

A 6-year-old, 24.3 kg girl undergoing dental rehabilitation

Family history of MH

Induction with propofol. Maintenance of anesthesia with remimazolam (5 - 7 µg/kg/min) and propofol (50 µg/kg/min). Analgesia with morphine and ketorolac.

Kiyokawa et al [44]

A 5-year-old boy undergoing inguinal herniorrhaphy

Medium chain acyl dehydrogenase deficiency

Induction with remimazolam (4 mg bolus). Maintenance of anesthesia with remimazolam (2 mg/kg/h) and remifentanil (0.5 µg/kg/min). NM blockade - rocuronium. Depth of anesthesia monitored with the BIS. Rectus sheath and ilioinguinal nerve blockade.