A systematic review of perioperative seizure prophylaxis during brain tumor resection: the case for a multicenter randomized clinical trial

Vyshak Chandra, Andrew K. Rock, Charles Opalak, Joel M. Stary, Adam P. Sima, Matthew Carr, Rafael A. Vega, William C. Broaddus
2017 Neurosurgical Focus  
FOCUS Neurosurg Focus 43 (5): E18, 2017 S eizureS are debilitating and burdensome for the health care system. Patients with seizures have higher medical expenses, lower employment rates, and barriers to social participation. 11 Seizures lead to longer hospital stays and increased health care costs. The risk of new-onset seizure for a patient with a brain tumor is reported to be 20%-90%. 7,12,20 Postcraniotomy seizure rates for patients with no prior history of seizure range from 7% to 18%. 4,5
more » ... rom 7% to 18%. 4,5 Antiepileptic drugs (AEDs) have been used to decrease the rate of postoperative seizures. This prac-tice was first studied in the 1980s, with investigators in a double-blind trial concluding that preoperative phenytoin administration decreased seizure rates by 50%; 20 however, the study included craniotomies for a variety of pathologies, and there was no significant difference in seizure rates between the AED-treated and untreated supratentorial tumor resection groups. A 2015 survey of surgeons revealed that more than 63% of them administer seizure prophylaxis after tumor resection in patients without a history of seizures. 3 Eighty-five ABBREVIATIONS AED = antiepileptic drug; RCT = randomized controlled trial. OBJECTIVE The majority of neurosurgeons administer antiepileptic drugs (AEDs) prophylactically for supratentorial tumor resection without clear evidence to support this practice. The putative benefit of perioperative seizure prophylaxis must be weighed against the risks of adverse effects and drug interactions in patients without a history of seizures. Consequently, the authors conducted a systematic review of prospective randomized controlled trials (RCTs) that have evaluated the efficacy of perioperative seizure prophylaxis among patients without a history of seizures. METHODS Five databases (PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL/Academic Search Complete, Web of Science, and ScienceDirect) were searched for RCTs published before May 2017 and investigating perioperative seizure prophylaxis in brain tumor resection. Of the 496 unique research articles identified, 4 were selected for inclusion in this review. RESULTS This systematic review revealed a weighted average seizure rate of 10.65% for the control groups. There was no significant difference in seizure rates among the groups that received seizure prophylaxis and those that did not. Further, this expected incidence of new-onset postoperative seizures would require a total of 1258 patients to enroll in a RCT, as determined by a Farrington-Manning noninferiority test performed at the 0.05 level using a noninferiority difference of 5%. CONCLUSIONS According to a systematic review of major RCTs, the administration of prophylactic AEDs after brain tumor resection shows no significant reduction in the incidence of seizures compared with that in controls. A large multicenter randomized clinical trial would be required to assess whether perioperative seizure prophylaxis provides benefit for patients undergoing brain tumor resection. https://thejns.org/doi/abs/10.3171/2017.8.FOCUS17442
doi:10.3171/2017.8.focus17442 pmid:29088958 fatcat:pesdsmk5djcerlctbf6ai7que4