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Meta-Analysis
. 2025 Aug 14;61(8):1463.
doi: 10.3390/medicina61081463.

Total Intravenous Versus Inhalational Anesthesia in High-Grade Glioma Surgery: A Systematic Review and Meta-Analysis

Plamen Penchev  1 , Boris Tablov  2 , Mariano Gallo Ruelas  3 , Daniela Milanova-Ilieva  4 , Lyubomir Gaydarski  5 , Nikolay Yordanov  6 , Eduardo Alonso  7 , Danna Espinoza  7 , Petar-Preslav Petrov  8 , Ivelina Lukanova  9 , Pavel Stanchev  10 , Julian Dichev  1 , Ivana Korentova  11 , Nikolai Ramadanov  12   13
Affiliations
Meta-Analysis

Total Intravenous Versus Inhalational Anesthesia in High-Grade Glioma Surgery: A Systematic Review and Meta-Analysis

Plamen Penchev et al. Medicina (Kaunas). .

Abstract

Background and Objectives: High-grade gliomas (HGGs) are aggressive primary brain tumors with a poor prognosis despite multimodal treatment. The anesthetic technique used during surgery may influence tumor progression and survival, but its role in HGGs remains unclear. This meta-analysis evaluated the effect of total intravenous anesthesia (TIVA) versus inhalational anesthesia (INHA) on overall survival (OS) and progression-free survival (PFS) in HGG patients. Materials and Methods: A systematic search was conducted in PubMed, Scopus, and Cochrane databases for studies assessing the impact of TIVA versus INHA on OS and PFS in HGG patients. Statistical analysis was performed using R version 4.3.1. Heterogeneity across studies was quantified using the Cochrane Q test alongside the I2 statistic. A random-effects model was employed to derive the pooled hazard ratios (HRs). Results: A total of five studies involving 827 participants (mean age 58 years, mean females 38%) were included, of whom 406 (49%) received TIVA. No statistically significant differences were observed in OS (HR 0.77; 95% CI [0.58-1.02]; p = 0.07; I2 = 67%) or PFS (HR 0.88; 95% CI [0.70-1.10]; p = 0.27; I2 = 51%) between the groups. A subgroup analysis revealed that TIVA was associated with improved OS in patients with grade IV tumors (HR 0.70; 95% CI [0.51-0.96]; p = 0.03), while no significant effect was observed in the mixed grade III-IV subgroup. However, the test for subgroup differences was not statistically significant (p = 0.0669), and this finding should be interpreted with caution. No significant differences were observed in median OS or PFS, or in single-arm meta-analyses. Conclusions: This meta-analysis found no statistically significant differences in overall or progression-free survival between TIVA and INHA in patients undergoing surgery for HGGs. Although a subgroup analysis suggested a possible survival advantage of TIVA in grade IV tumors, the lack of a statistically significant subgroup difference test limits the strength of this finding. Further investigation is needed to determine whether anesthetic technique influences outcomes in this subgroup.

Keywords: glioblastoma; high-grade gliomas; inhalational anesthesia (INHA); total intravenous anesthesia (TIVA).

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
PRISMA flow diagram and study selection.
Figure 2
Figure 2
In terms of overall survival, no statistically significant differences were observed [1,2,3,4,5].
Figure 3
Figure 3
Regarding OS, the overall effect size remained consistent across all iterations and the result remained non-significant in all cases [1,2,3,4,5].
Figure 4
Figure 4
The Baujat plot for OS showing the contribution of individual studies to overall heterogeneity and their influence on the overall meta-analysis results [1,2,3,4,5].
Figure 5
Figure 5
No statistically significant differences emerged based on risk of bias assessment differences between the subgroups [1,2,3,4,5].
Figure 6
Figure 6
Regarding PFS, no statistically significant differences were observed between the groups [1,2,3,5].
Figure 7
Figure 7
Regarding PFS, the overall effect size remained consistent across all iterations and the result remained non-significant in all cases [1,2,3,5].
Figure 8
Figure 8
The Baujat plot for PFS showing the contribution of individual studies to overall heterogeneity and their influence on the overall meta-analysis results [1,2,3,5].
Figure 9
Figure 9
In terms of mOS, there were no statistically significant differences between the groups [1,2,3,4,5].
Figure 10
Figure 10
Regarding mOS, the overall effect size remained consistent across all iterations and the result remained non-significant in all cases [1,2,3,4,5].
Figure 11
Figure 11
The Baujat plot for mOS showing the contribution of individual studies to overall heterogeneity and their influence on the overall meta-analysis results [1,2,3,4,5].
Figure 12
Figure 12
Risk of bias-based subgroup analysis revealed no significant differences between the groups [1,2,3,4,5].
Figure 13
Figure 13
Regarding mOS, there were no statistically significant differences between the subgroups [1,2,3,4,5].
Figure 14
Figure 14
In terms of mPFS, there were no statistically significant differences between the groups [1,2,3,5].
Figure 15
Figure 15
Regarding mPFS, the overall effect size remained consistent across all iterations and the result remained non-significant in all cases [1,2,3,5].
Figure 16
Figure 16
The Baujat plot for mPFS showing the contribution of individual studies to overall heterogeneity and their influence on the overall meta-analysis results [1,2,3,5].
Figure 17
Figure 17
In terms of mPFS, there were no statistically significant differences between the subgroups [1,2,3,5].
Figure 18
Figure 18
Regarding OS, there was a significant effect in the grade IV-only subgroup, but no significant differences were found between the subgroups [1,2,3,4,5].
Figure 19
Figure 19
Regarding OS, the overall effect size remained consistent across all iterations and the result remained non-significant in all cases [1,2,3,4,5].
Figure 20
Figure 20
The Baujat plot for OS showing the contribution of individual studies to overall heterogeneity and their influence on the overall meta-analysis results [1,2,3,4,5].
Figure 21
Figure 21
Regarding PFS, no statistically significant differences were observed within each subgroup or between the subgroups [1,2,3,5].
Figure 22
Figure 22
Regarding PFS, the overall effect size remained consistent across all iterations, and the results remained non-significant in all cases [1,2,3,5].
Figure 23
Figure 23
The Baujat plot for PFS showing the impact of individual studies on overall heterogeneity and their influence on meta-analysis outcomes [1,2,3,5].
Figure 24
Figure 24
Publication bias evaluation for OS was assessed by plotting individual study weights against point estimates.
Figure 25
Figure 25
Publication bias for PFS was assessed by plotting individual study weights against their point estimates.
Figure 26
Figure 26
Publication bias for mOS was evaluated by plotting individual study weights against their point estimates.
Figure 27
Figure 27
Publication bias for mPFS was assessed by plotting individual study weights against their point estimates.
Figure 28
Figure 28
Risk of bias assessment [1,2,3,4,5].
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