gms | German Medical Science

Objective: The practice of administering antiepileptic drugs (AED) prophylactically for craniotomies at the time of surgery, regardless of whether the patient has experienced a seizure has been the aim of previous studies reaching conflicting results and remains controversial. The reasoning presupposes that the possibility of an adverse drug reaction from the AED is lower than the probability of harm from a seizure. Hemodynamic effects and tolerability of Levetiracetam (LEV) combined with Lacosamide (LCM) were compared with Phenytoin (PHT) retrospectively when used as perioperative seizure prophylaxis in patients undergoing craniotomy.

Methods: Between January and September 2011 in a single institution, patients undergoing a craniotomy were studied retrospectively. Patients already receiving LEV as AED preoperatively, received LCM as add-on therapy for seizure prophylaxis in supratentorial brain surgery and were compared with a patient collective receiving PHT from an earlier study. Seizures or adverse events documented during the first seven days after craniotomy were considered as side effects. Furthermore, derived from the anaesthesia-protocol, the cumulative dose of norepinephrin (NET), atropine (ATR) and the change in systolic blood pressure during and after the administration of the AED were analyzed.

Results: Data of 538 patients treated with an AED were evaluated. 41 patients with primary or secondary supratentorial brain tumors received LEV and LCM, 41 patients PHT. The mean age was 55 and 49 years, respectively. Male to female ratio was 61/39% and 63/37%. Low-grade gliomas in 32% (15%), Glioblastoma in 29% (37%), brain metastases in 10% (12%), meningiomas in 17% (24%), PCNSL in 5 % (2%) and abscess in 7 % (10%). 1 LEV and LCM patient (2%) and 4 PHT patients (4.5%) had a seizure despite this treatment. Side effects were observed in 2 patients associated with PHT, including hepatotoxicity and intraoperative arrhythmia. During anesthesia there was a significant drop in systolic blood pressure in the PHT group after administration of the AED perioperatively when compared to LEV and LCM. Higher doses and more frequent administration of NET tended to be associated with PHT when used as seizure prophylaxis. Mean operating time was 3:19 h vs. 3:47 h (not significant).

Conclusions: LEV in combination with LAC for patients with symptomatic epilepsy as perioperative AED provides a safe and feasible alternative to PHT, which frequently is associated with episodes of hypotension during anesthesia.