Skeletal Muscle Relaxants and Their Impact on Intracranial Pressure in Neurosurgery

Łukasz Grabarczyk; Huang Wen-Tau; Małgorzata Rymsza; Agnieszka Stankiewicz; Marta Dobrzeniecka-Al Dhaif; Maciej Szewczyk

doi:10.12659/MSM.946569

03 January 2025 : Review article

Skeletal Muscle Relaxants and Their Impact on Intracranial Pressure in Neurosurgery

Łukasz Grabarczyk

^1ABCDEFG, Huang Wen-Tau^2ABCDEF, Małgorzata Rymsza^2ABCDEF, Agnieszka Stankiewicz^2ABCDEF, Marta Dobrzeniecka-Al Dhaif^2ABCDEF, Maciej Szewczyk

^3ABCDEFG*

DOI: 10.12659/MSM.946569

Med Sci Monit 2025; 31:e946569

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Introduction Symptoms of Increased Intracranial Pressure Assessment of High Intracranial Pressure Treatment Methods for Increased Intracranial Pressure Succinylcholine’s Characteristics and Use in Patients Undergoing Neurosurgery Characteristics of Benzylisoquinoline Characteristics of Atracurium Atracurium’s Effect on Intracranial Pressure and Use in Neurosurgery Characteristics of Cisatracurium Use of Cisatracurium in Neurosurgery Mivacurium’s Characteristics and Impact on Intracranial Pressure in Patients Undergoing Neurosurgery Aminosteroid Neuromuscular Blocking Agents Characteristics of Pipecuronium Characteristics of Pancuronium Comparison of Use of Pipecuronium and Pancuronium in Neurosurgery Vecuronium’s Characteristics and Use in Neurosurgery Characteristics of Rocuronium Rocuronium’s Use in Neurosurgery Reversal Agents Characteristics of Neostigmine Characteristics of Sugammadex Use of Sugammadex and Neostigmine in Neurosurgery Patients Conclusions Future Directions References

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Table 1 Summary of main effects of different neuromuscular blocking agents (NBMA) of the revised clinical studies. Studies are assigned to specific NBMAs and presented in reverse chronological order. For each study, the first author, year of publication, number of patients studied, NMBA used, most relevant cerebrovascular effects, and corresponding reference are provided.

Drug group	NMBA	Cerebrovascular effects	First Author, year	Reference	Patients (n)	Control group
Depolarizing agent	Succinylcholine	ICP does not change	Kovarik, 1994	[]²⁰	10	Same patient
		ICP increased	Stirt, 1987	[]²¹	12	Two groups
		ICP increased	Minton, 1986	[]¹⁹	13	Same patient
Benzylisoquinolines	Atracurium	ICP, CPP, CBFV, and MAP decreased	Schramm, 1998	[]³⁰	14	Same patient
		Control of otherwise unstable ICP	McClelland, 1995	[]²⁹	4	Same patient
		No changes in ICP, CPP, or MAP	Unni, 1986	[]²⁷	9	Same patient
		No changes in ICP, MAP, CVP, HR, and etCO2	Rosa, 1986	[]²⁶	25	Same patient
		No changes in ICP, CPP, or MAP	Minton, 1985	[]²⁵	20	Two groups
	Cisatracurium	Prevention of increase in ICP	Chivite Fernández, 2005	[]⁴⁸	13	Same patient
		No changes in ICP, CPP, CBFV, and MAP	Schramm 1998	[]³⁰	14	Same patient
		No changes in ICP, CPP, CBFV, MAP, and HR regardless of dose	Schramm, 1997	[]³¹	24	Two groups
	Mivacurium	No changes in ICP, CSFP or MAP	Cafiero, 1999	[]³⁵	12	Same patient
Aminosteroids	Pancuronium	ICP decreased, elevated HR and arterial pressure	Thiel, 1996	[]⁴¹	10	Two groups
	Pipecuronium	ICP decreased, stable HR and arterial pressure	Thiel, 1996	[]⁴¹	10	Two groups
	Pipecuronium	No changes in ICP, MAP, CVP, HR, and etCO2	Di Giugno, 1992	[]⁴⁹	10	Same patient
	Rocuronium	No significant changes in ICP, MAP, CPP. Treatment caused slight increase in HR	Schramm, 1996	[]⁴⁷	20	Two groups
	Vecuronium	ICP increased	Kerwin 2000	[]⁵⁰	23	Same patient
		Treatment caused no significant changes in ICP, CPP, or MAP	Schramm, 1996	[]⁴⁷	20	Two groups
		ICP slightly decreased	Rosa, 1986	[]⁴³	20	Same patient
ICP – intracranial pressure; CPP – cerebral perfusion pressure; CBFV – cerebral blood flow velocity; MAP – mean arterial pressure; CVP – central venous pressure; HR – heart rate; etCO2 – end-tidal CO2; CSFP – cerebrospinal fluid pressure.

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Skeletal Muscle Relaxants and Their Impact on Intracranial Pressure in Neurosurgery

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