Background <p>Previous studies have suggested that propofol can reduce intracranial pressure (ICP). However, the effects of remimazolam, a new intravenous anesthetic, on ICP remain unknown. This study aimed to compare the effects of remimazolam and propofol on the ICP in patients undergoing laparoscopic hysterectomy by measuring the optic nerve sheath diameter (ONSD) using ultrasound.</p> Methods <p>A total of 60 patients scheduled for elective laparoscopic hysterectomy were randomly assigned to remimazolam group (0.3&#xa0;mg/kg induction, 1–2&#xa0;mg/kg/h infusion) and propofol group (2&#xa0;mg/kg induction, 4–8&#xa0;mg/kg/h infusion). The ONSD was measured 5&#xa0;min after induction of anesthesia in the supine position (T1); 15&#xa0;min (T2), 30&#xa0;min (T3), and 60&#xa0;min (T4) following the establishment of pneumoperitoneum and the Trendelenburg position; and at 5&#xa0;min after desufflation in the supine position (T5). Respiratory and hemodynamic variables, postoperative nausea and vomiting, and headache were also recorded.</p> Results <p>Compared with the ONSD measured at T1, the ONSD at T2-T5 were significantly increase in both groups (<i>P</i>&lt;0.05), whereas the extent of change in ONSD at T2-T5 showed no significant differences between the propofol group and remimazolam group (7.30% vs. 8.11%, 9.45% vs. 10.41%, 9.37% vs. 10.31%, 4.26% vs. 4.25%, <i>P</i>&gt;0.05).</p> Conclusions <p>The extent of the increase in ONSD during the laparoscopic hysterectomy has no significantly difference between remimazolam and propofol anesthesia, suggesting that remimazolam and propofol may have similar effects on ICP.</p> Trial registration <p>This trial was retrospectively registered in the Chinese Clinical Trial Registry on April 18, 2025 (Registration Number: ChiCTR 2500101025).</p>