Craniotomy presents true anesthetic challenges, mainly due to the need to optimize cerebral perfusion, facilitate brain relaxation, achieve rapid emergence for neurologic assessment, and minimize perioperative complications.

Total intravenous anesthesia, particularly with propofol-based regimens, has gained favor in neurosurgical procedures for its neuroprotective properties, and reduced intracranial pressure; however, the choice of adjunct agents in total intravenous anesthesia remains a subject of ongoing investigation, especially regarding their influence on hemodynamic stability, analgesia, brain relaxation, and postoperative outcomes.

Total intravenous anesthesia techniques for craniotomy allow rapid recovery and stable hemodynamic parameters, so they decrease the hospital stay. The current study will compare the efficacy and safety profiles of dexmedetomidine, fentanyl, and magnesium sulfate as adjuncts in total intravenous anesthesia for patients undergoing craniotomy.

Inclusion Criteria:

• Patient acceptance.
• Physical status: American Society of Anesthesiologists Physical Status (ASA) 1& II.
• Body mass index ≤ 30 kg/m2.
• Type of operation: elective craniotomy for brain tumor resection.
• Duration of surgery: within 4 hours.

Exclusion Criteria:

• Patient with hemodynamic instability or anticipated postoperative mechanical ventilation.
• Patients with a known history of allergy to the study drugs.
• Advanced hepatic, renal, cardiovascular, and neurologic diseases.
• Patients with chronic opioid use.