Comparison of nicardipine and esmolol for intraoperative blood pressure control during awake deep brain stimulation surgery: a retrospective study

Aim: Awake deep brain stimulation (DBS) surgery requires the patient to remain conscious for optimal electrode placement through intraoperative neurophysiological monitoring. However, hypertension during awake DBS poses significant clinical challenges, potentially compromising surgical accuracy and patient safety. Nicardipine and esmolol are both used for intraoperative blood pressure control, but their comparative efficacy in awake DBS remains unclear. The aim of this study was to compare the effectiveness of nicardipine and esmolol in controlling intraoperative blood pressure during awake DBS surgery under monitored anesthesia care. Material and Methods: This retrospective study evaluated patients who underwent awake DBS surgery under MAC between January 2020 and April 2025. Forty adult patients experiencing intraoperative hypertension (systolic arterial pressure [SAP] ≥150 mmHg) were included and divided into two groups based on the antihypertensive agent administered: nicardipine (n = 20) or esmolol (n = 20). Hemodynamic parameters, antihypertensive requirements, and intraoperative complications were compared between the groups. Results: Mean intraoperative SAP was significantly lower in the nicardipine group compared to the esmolol group (121.9 ± 2.6 mmHg vs. 127.9 ± 3.5 mmHg, p = 0.04). Although the frequency of hypertensive episodes tended to be lower with nicardipine, this did not reach statistical significance (15.9% ± 3.6 vs. 26.1% ± 4.1, p = 0.21). Esmolol resulted in significantly lower heart rates (69.2 ± 2.8 bpm vs. 87.9 ± 2.0 bpm, p = 0.01) but required higher doses of rescue antihypertensives (glyceryl trinitrate: 53.1 ± 5.8 mg vs. 25.8 ± 1.2 mg, p < 0.001). No major intraoperative complications or conversions to general anesthesia occurred in both groups. Conclusions: Nicardipine provided more effective and stable intraoperative blood pressure control than esmolol during awake DBS surgery, reducing the need for additional antihypertensive medications. Both agents were safely administered without compromising patient cooperation or neurophysiological monitoring. Therefore, nicardipine may be preferable due to the less need for rescue antihypertensive treatment.