The Influence of Perioperative Seizure Prophylaxis on Seizure Rate and Hospital Quality Metrics Following Glioma Resection

Prevalence and risk factors of early postoperative seizures in patients with glioma: A protocol for meta-analysis and systematic review

INTRODUCTION

Early postoperative seizures has been the most common clinical expression in gliomas; however, the incidence and risk factors for early postoperative seizures in gliomas are more controversial. This protocol describes a systematic review and meta-analysis to clarify the prevalence and risk factors of early postoperative seizures in patients with glioma.

METHODS AND ANALYSIS

Searches will be conducted on CNKI, WanFang, VIP, PubMed, Embase, Cochrane Library databases and Web of Science for the period from database inception to December 31st, 2023. Case-control and cohort studies of the incidence and risk factors for early postoperative seizures in all gliomas will be included. The primary outcome will be incidence, risk factors. Newcastle-Ottawa Scale was used for quality evaluation. Review of article screening, extracting data and risk of bias assessment will be repeated by two independent reviewers.

RESULT

This study will provide evidence for the risk factors and incidence of early postoperative seizures in patients with glioma.

CONCLUSION

Our study will provide evidence for the prevention of early postoperative seizures in glioma patients.

TRAIL REGISTRATION

This protocol was registered in PROSPERO and registration number is CRD42023415658.

Perioperative perampanel administration for early seizure prophylaxis in brain tumor patients

Background

The efficacy of perioperative prophylactic antiepileptic drug therapy in "seizure-naïve" patients with brain tumor, including glioblastoma (GBM), remains controversial. This study investigated whether perampanel (PER) is effective and safe for preventing perioperative onset of epileptic seizures, so-called early seizure, in patients with brain tumors.

Methods

Forty-five patients underwent tumor resection through craniotomy for a primary supratentorial brain tumor at Ehime University Hospital between April 2021 and July 2022. PER was administered from the 1st to the 6th day after surgery for seizure prophylaxis. Occurrence of early seizure, hematological toxicities, and various side effects were recorded on postoperative days 7 and 14. In addition, the clinical course of these patients was compared with 42 brain tumor patients under the same treatment protocol who received levetiracetam (LEV) for seizure prophylaxis between April 2017 and October 2018.

Results

In 45 patients with brain tumor, including GBM, who received PER administration, no early seizures were identified within 7 days postoperatively. No adverse drug reactions such as hematological toxicity, liver or kidney dysfunction, or exanthematous drug eruption were observed in any cases. As side effects, somnolence was reported in 14 patients (31.1%), vertigo in 3 patients (6.7%), and headache in 3 patients (6.7%). Although somnolence and vertigo were difficult to assess in the case of intraparenchymal tumors, particularly GBM, these side effects were not identified in patients with extraparenchymal tumors such as meningiomas, epidermoid cysts, and pituitary adenomas. In addition, no significant differences were identified compared to patients who received LEV.

Conclusion

The efficacy and safety of PER in preventing early seizures among patients with brain tumors were retrospectively evaluated. Perioperative administration of PER to patients with brain tumors may reduce the risk of early seizures without incurring serious side effects, showing no significant differences compared to patients who received LEV.

Brain Tumor Rehabilitation: Symptoms, Complications, and Treatment Strategy

Brain tumors are receiving increasing attention in cancer rehabilitation due to their high rate of neurological deterioration. Motor dysfunction, cognitive deterioration, and emotional problems are commonly present in patients with brain tumors. Other medical complications, such as seizures, headache, and dysphagia are also common. An individualized multidisciplinary rehabilitation intervention is necessary to treat functional impairment due to the tumor itself and/or treatment-related dysfunction. Herein, we discuss rehabilitation treatment strategies in relation to the neurological and functional complications that commonly occur in patients with brain tumors.

Perioperative levetiracetam for seizure prophylaxis in seizure-naive brain tumor patients with focus on neurocognitive functioning

Introduction

In seizure-naive brain tumor patients, the efficacy of perioperative prophylactic antiepileptic drug treatment remains controversial. In case of administration, the common preferred drug is levetiracetam (LEV) because of its favorable pharmacological profile. Research to date has not sufficiently determined how LEV affects cognition in the short term, as is the case in the perioperative period. The objective of this prospective study was to examine the neurocognitive functioning of seizure-naive brain tumor patients after receiving LEV perioperatively.

Methods

Fortythree patients with supratentorial brain tumor scheduled for surgery received LEV three days before until six days after surgery as seizure prophylaxis. Cognitive functioning (NeuroCogFX), LEV plasma-levels, hematotoxicity, side-effects, as well as health-related quality of life (HRQoL, Qolie31), were recorded preoperatively before (Baseline) and after onset of LEV (Pre-Op), 4–6 days postoperatively (Post-Op) and 21 days postoperatively (Follow-Up).

Results

No significant changes in cognitive functioning and HRQoL were seen after onset of preoperative LEV. There was a significant improvement of NeuroCogFX total-score at Follow-Up (p = 0.004) compared to Baseline. The overall-score Qolie31 showed simultaneous improvement patterns as cognitive functioning (p < 0.001). The most frequent side effect related to study drug was somnolence (in 28.6% of patients).

Conclusions

A significant improvement of cognitive functioning, as well as an improvement in HRQoL, were detected postoperatively. This is presumably due to the debulking effect of the surgery. Nevertheless, LEV has no detrimental effect on cognitive functioning in the perioperative phase in seizure-naive brain tumor patients.

Trial registration

This study was registered prospectively (Date: 25/11/2015; EudraCT: 2015–003,916-19).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02762-7.

Incidence, risk factors, and outcomes for early postoperative seizures in dogs with rostrotentorial brain tumors after intracranial surgery

Background

Seizures in the early postoperative period after intracranial surgery may affect outcome in dogs.

Objectives

To determine the incidence of early postoperative seizures (EPS) in dogs with brain tumors, identify specific risk factors for EPS, and determine if EPS affects outcome.

Animals

Eighty‐eight dogs that underwent 125 intracranial surgeries for diagnosis and treatment of rostrotentorial brain tumors.

Methods

Retrospective cohort study. All patients with a diagnosis of rostrotentorial brain tumor from 2006 to 2020 were included. Early postoperative seizures were diagnosed by observation of seizure activity within 14 days of neurosurgery. Previously diagnosed structural epilepsy, perioperative anticonvulsant drug (ACD) use, magnetic resonance imaging (MRI), and tumor characteristics were evaluated. Outcome measures included neurologic and nonneurologic complications, duration of hospitalization, and survival to discharge.

Results

Dogs with rostrotentorial brain tumors had EPS after 16/125 (12.8%) neurosurgical procedures (95% confidence interval [CI], 7%‐19%). Presence of previous structural epilepsy was not associated with EPS risk (P = 1). Perioperative ACD use also was not associated with EPS (P = .06). Dogs with EPS had longer hospitalization (P < .001), were more likely to have neurologic complications postsurgery (P = .01), and were less likely to survive to discharge (P = .01).

Conclusions and Clinical Importance

It is difficult to predict which dogs are at risk of EPS because the presence of previous structural epilepsy and the use of perioperative ACDs was not associated with EPS. However, seizures in the early postoperative period are clinically important because affected dogs had prolonged hospitalization, more neurologic complications, and decreased short‐term survival.

Predictors of early postoperative epileptic seizures after awake surgery in supratentorial diffuse gliomas

OBJECTIVE

Functional-based resection under awake conditions had been associated with a nonnegligible rate of intraoperative and postoperative epileptic seizures. The authors assessed the incidence of intraoperative and early postoperative epileptic seizures after functional-based resection under awake conditions.

METHODS

The authors prospectively assessed intraoperative and postoperative seizures (within 1 month) together with clinical, imaging, surgical, histopathological, and follow-up data for 202 consecutive diffuse glioma adult patients who underwent a functional-based resection under awake conditions.

RESULTS

Intraoperative seizures occurred in 3.5% of patients during cortical stimulation; all resolved without any procedure being discontinued. No predictor of intraoperative seizures was identified. Early postoperative seizures occurred in 7.9% of patients at a mean of 5.1 ± 2.9 days. They increased the duration of hospital stay (p = 0.018), did not impact the 6-month (median 95 vs 100, p = 0.740) or the 2-year (median 100 vs 100, p = 0.243) postoperative Karnofsky Performance Status score and did not impact the 6-month (100% vs 91.4%, p = 0.252) or the 2-year (91.7 vs 89.4%, p = 0.857) postoperative seizure control. The time to treatment of at least 3 months (adjusted OR [aOR] 4.76 [95% CI 1.38–16.36], p = 0.013), frontal lobe involvement (aOR 4.88 [95% CI 1.25–19.03], p = 0.023), current intensity for intraoperative mapping of at least 3 mA (aOR 4.11 [95% CI 1.17–14.49], p = 0.028), and supratotal resection (aOR 6.24 [95% CI 1.43–27.29], p = 0.015) were independently associated with early postoperative seizures.

CONCLUSIONS

Functional-based resection under awake conditions can be safely performed with a very low rate of intraoperative and early postoperative seizures and good 6-month and 2-year postoperative seizure outcomes. Intraoperatively, the use of the lowest current threshold producing reproducible responses is mandatory to reduce seizure occurrence intraoperatively and in the early postoperative period.

Clinical Diagnosis and Perioperative Management of Glioma-Related Epilepsy

Gliomas account for more than half of all adult primary brain tumors. Epilepsy is the most common initial clinical presentation in gliomas. Glioma related epilepsy (GRE) is defined as symptomatic epileptic seizures secondary to gliomas, occurring in nearly 50% in high-grade glioma (HGG) patients and up to 90% in patients with low-grade glioma (LGG). Uncontrolled seizures, which have major impact on patients’ quality of life, are caused by multiple factors. Although the anti-seizure medications (ASMs), chemotherapy and radiation therapy are also beneficial for seizure treatment, the overall seizure control for GRE continue to be unsatisfactory. Due to the close relationship between GRE and glioma, surgical resection is often the treatment of choice not only for the tumor treatment, but also for the seizure control. Despite aggressive surgical treatment, there are about 30% of patients continue to have poor seizure control postoperatively. Furthermore, the diagnostic criteria for GRE is not well established. In this review, we propose an algorithm for the diagnosis and perioperative management for GRE.

Antiepileptic Drugs in the Management of Cerebral Metastases

Seizures represent a common and debilitating complication of central nervous system metastases. The use of prophylactic antiepileptic drugs (AEDs) in the preoperative period remains controversial, but the preponderance of evidence suggests that it is not helpful in preventing seizure and instead poses a significant risk of adverse events. Studies of postoperative seizure prophylaxis have not shown substantial benefit, but this practice remains widespread. Careful analysis of the risk of seizure based on patient-specific factors, such as tumor location and primary tumor histology, should guide the physician's decision on the initiation and cessation of prophylactic AED therapy.

Early postoperative seizures (EPS) in patients undergoing brain tumour surgery

Early postoperative seizures (EPS) are a common complication of brain tumour surgery. This paper investigates risk factors, management and clinical relevance of EPS. We retrospectively analysed the occurrence of EPS, clinical and laboratory parameters, imaging and histopathological findings in a cohort of 679 consecutive patients who underwent craniotomies for intracranial tumours between 2015 and 2017. EPS were observed in 34/679 cases (5.1%), with 14 suffering at least one generalized seizure. Patients with EPS had a worse postoperative Karnofsky performance index (KPI; with EPS, KPI < 70 vs. 70-100: 11/108, 10.2% vs. 23/571, 4.0%; p = 0.007). Preoperative seizure history was a predictor for EPS (none vs. 1 vs. ≥ 2 seizures: p = 0.037). Meningioma patients had the highest EPS incidence (10.1%, p < 0.001). Cranial imaging identified a plausible cause in most cases (78.8%). In 20.6%, EPS were associated with a persisting new neurological deficit that could not otherwise be explained. 34.6% of the EPS patients had recurrent seizures within one year. EPS require an emergency work-up. Multiple EPS and recurrent seizures are frequent, which indicates that EPS may also reflect a more chronic condition i.e. epilepsy. EPS are often associated with persisting neurological worsening.

Radiomics Analysis of Postoperative Epilepsy Seizures in Low-Grade Gliomas Using Preoperative MR Images

Purpose: The present study aimed to evaluate the performance of radiomics features in the preoperative prediction of epileptic seizure following surgery in patients with LGG. Methods: This retrospective study collected 130 patients with LGG. Radiomics features were extracted from the T2-weighted MR images obtained before surgery. Multivariable Cox-regression with two nested leave-one-out cross validation (LOOCV) loops was applied to predict the prognosis, and elastic net was used in each LOOCV loop to select the predictive features. Logistic models were then built with the selected features to predict epileptic seizures at two time points. Student's t-tests were then used to compare the logistic model predicted probabilities of developing epilepsy in the epilepsy and non-epilepsy groups. The t-test was used to identify features that differentiated patients with early-onset epilepsy from their late-onset counterparts. Results: Seventeen features were selected with the two nested LOOCV loops. The index of concordance (C-index) of the Cox model was 0.683, and the logistic model predicted probabilities of seizure were significantly different between the epilepsy and non-epilepsy groups at each time point. Moreover, one feature was found to be significantly different between the patients with early- or late-onset epilepsy. Conclusion: A total of 17 radiomics features were correlated with postoperative epileptic seizures in patients with LGG and one feature was a significant predictor of the time of epilepsy onset.

Cranioplasty length of stay: Relationship with indication, surgical decision-making factors, and sex

Objectives

Cranioplasty is being performed more often due to rising rates of decompressive craniectomy. Hospital length of stay is a quality metric which has not been directly studied after cranioplasty. This study aims to identify factors associated with length of stay after cranioplasty to better understand their outcomes.

Patients and methods

A retrospective review was conducted at a single academic center from 2007 to 2015 for all patients >18 years of age who received cranioplasty. Baseline data from 148 patients were recorded including demographics, clinical characteristics, and surgeon decision-making factors for cranioplasty. Post-operative complications within 30 days after cranioplasty were recorded in addition to disposition and discharge data. Weibull accelerated failure time models were used to identify significant associations with length of stay after cranioplasty.

Results

The overall post-operative complication rate was 27.0%, and the most frequent indication for craniectomy was traumatic brain injury. The majority (72.3%) of patients returned home, compared to other disposition, and median length of stay was 2.0 days (interquartile range = 2.0). Average length of stay was 7.7 days in men, as compared with 2.4 days in women, and even upon adjusting for covariate effects, length of stay was longer in men than in women irrespective of post-operative complications. When time-to-cranioplasty fell between 0 and 30 days, average length of stay was 19.2 days, as compared with 10.3 days when time-to-cranioplasty fell between 30 and 90 days, and 2.5 days when time-to-cranioplasty was >90 days. After adjustment for covariate effects, the association between time-to-cranioplasty and length of stay was maintained only in patients without post-operative complications.

Conclusions

Length of stay can inform our understanding of outcomes after cranioplasty. In our study, length of stay was associated with sex, indication for craniectomy, and surgical decision-making (time-to-cranioplasty and implant material), but time-to-cranioplasty was only associated in patients without post-operative complications. These relationships should be seen not as direct causation, but rather as tools to add to our understanding of this relatively complicated procedure.

Efficacy of perioperative anticonvulsant prophylaxis in seizure-naïve glioma patients: A meta-analysis

The efficacy of perioperative seizure prophylaxis in seizure-naïve glioma patients is still controversial. Thus we conducted this meta-analysis to assess the effectiveness of perioperative prophylactic antiepileptic drugs (AEDs) on postoperative seizures in seizure-naïve glioma for the first time. We systematically searched PubMed, Embase, Weipu (VIP) and Chinese National Knowledge Infrastructure (CNKI) until July 5, 2019 for eligible studies. Fixed or random model was used to calculate the odds ratios in STATA 12.0 software. Subgroup analyses of early postoperative seizure, late postoperative seizure, high-grade glioma (WHOIII-IV) and phenytoin (PHT) or phenobarbital (PB) prophylaxis were conducted. Altogether 1143 seizure-naïve glioma patients from 9 studies were included in this meta-analysis, containing 643 prophylaxed and 503 non-prophylaxed patients. No significant association was detected between perioperative seizure prophylaxis and postoperative seizure occurrence in glioma patients without preoperative seizure history (OR = 0.91, 95% CI = 0.65-1.26, P = 0.56). Perioperative AED prophylaxis showed no significant benefit to postoperative seizures when stratified by early postoperative seizure(within the first postoperative week), late postoperative seizure (after the first postoperative week), high-grade glioma and PHT or PB prophylaxis (all P > 0.05). Current evidence indicated that perioperative seizure prophylaxis did not reduce the occurrence of postoperative seizure in seizure-naïve glioma patients. The pros and cons of perioperative seizure prophylaxis should be considered before the start of perioperative AEDs treatment.

Tarik Syndrome: Reversible Postoperative Blindness Secondary to Occipital Seizures

BACKGROUND

Postoperative blindness is a devastating surgical complication. Although usually associated with prolonged cardiac and prone spinal operations, it may follow other procedures as well. Postoperative blindness is most commonly caused by a vascular etiology, but it can more rarely be caused by status epilepticus. We have previously reported a case of this phenomenon following a staged spinal deformity surgery.

CASE DESCRIPTION

Here we report 2 additional cases following a skull base procedure and a single stage lumbar spine surgery. In all instances, rapid recognition that the patients' blindness was due to occipital seizures resulted in acute antiepileptiform treatment and full restoration of vision.

CONCLUSIONS

Although a rare phenomenon, this syndrome, first recognized and described by Tarik F. Ibrahim, should be considered in any patient with postoperative visual impairment.

Seizures in glioma patients: An overview of incidence, etiology, and therapies

Gliomas are fatal brain tumors, and even low-grade gliomas (LGGs) have an average survival of less than a decade. Seizures are a common presentation of gliomas, particularly LGGs, and substantially impact quality of life. Glioma-related seizures differ from other focal epilepsies in their pathogenesis and in the likelihood of refractory epilepsy. We review factors that predict seizure activity and response to treatment, optimal pharmacologic and surgical management of glioma-related epilepsy, and the benefit of using newer anti-seizure medications in patients with gliomas. As surgery is so often beneficial with seizure reduction, we discuss oncologic and epilepsy surgery perspectives. Treatment of gliomas has the potential to ameliorate seizures and increase rates of seizure freedom. Prospective, well-powered studies are needed to provide more definitive answers for practitioners taking care of glioma patients with seizures.

Clinical practice guidelines for the diagnosis and treatment of adult diffuse glioma-related epilepsy

BACKGROUND

Glioma-related epilepsy (GRE) is defined as symptomatic epileptic seizures secondary to gliomas, it brings both heavy financial and psychosocial burdens to patients with diffuse glioma and significantly decreases their quality of life. To date, there have been no clinical guidelines that provide recommendations for the optimal diagnostic and therapeutic procedures for GRE patients.

METHODS

In March 2017, the Joint Task Force for GRE of China Association Against Epilepsy and Society for Neuro-Oncology of China launched the guideline committee for the diagnosis and treatment of GRE. The guideline committee conducted a comprehensive review of relevant domestic and international literatures that were evaluated and graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence, and then held three consensus meetings to discuss relevant recommendations. The recommendations were eventually given according to those relevant literatures, together with the experiences in the diagnosis and treatment of over 3000 GRE cases from 24 tertiary level hospitals that specialize in clinical research of epilepsy, glioma, and GRE in China.

RESULTS

The manuscript presented the current standard recommendations for the diagnostic and therapeutic procedures of GRE.

CONCLUSIONS

The current work will provide a framework and assurance for the diagnosis and treatment strategy of GRE to reduce complications and costs caused by unnecessary treatment. Additionally, it can serve as a reference for all professionals involved in the management of patients with GRE.

Prophylactic antiepileptic treatment with levetiracetam for patients undergoing supratentorial brain tumor surgery: a two-center matched cohort study

Guidelines on the administration of prophylactic antiepileptic drugs (AED), and specifically levetiracetam, for brain tumor surgery are still lacking. In this two-center matched cohort study, we aim to compare the proportion of postoperative seizures during follow-up after supratentorial tumor surgery in patients receiving no seizure prophylaxis, and those treated with levetiracetam perioperatively. Three hundred sixteen consecutive patients undergoing supratentorial tumor surgery, without history of seizures were included: 207 patients did not receive AED (no AED group), and 109 patients received levetiracetam perioperatively (levetiracetam group). The primary outcome measure was the rate of postoperative seizures. Additionally, uni- and multivariate analyses assessing possible risk factors for postoperative seizures were performed. No statistically significant difference for the occurrence of postoperative seizures was found between the two groups (10.1%, n = 21 in the no AED group vs. 9.2%, n = 10, in the levetiracetam group; p = 0.69, OR 0.9 [0.4-2.0), NNT 103 [12.9-17.1]). After propensity score matching, the primary outcome was observed in 13 patients (12.4%) from the no AED group and in 9 patients (8.6%) from the levetiracetam group (p = 0.50, OR 0.7 [0.3-1.6], NNT 26.3 [8.3-22.4]). Among all analyzed possible risk factors for postoperative seizures, only postoperative infarction showed a statistically significant association with higher seizure rates in multivariate analysis (OR 8.2 [1.1-60.6], p = 0.04). Prophylactic treatment with levetiracetam after brain tumor surgery showed no statistically significant effect in preventing postoperative seizures. However, in case a postoperative infarction occurs, its administration might be indicated.

Antiepileptic drugs as prophylaxis for de novo brain tumour-related epilepsy after craniotomy: a systematic review and meta-analysis of harm and benefits

OBJECTIVES

To investigate potential harm and benefits of antiepileptic drugs (AED) given prophylactically to prevent de novo brain tumour-related epilepsy after craniotomy.

METHODS

Randomised controlled trials (RCT) and retrospective studies published before 27 November 2018 were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were applied. Eligible patients were diagnosed with a brain tumour, were seizure naïve and underwent craniotomy. The random effects model was used for quantitative synthesis. The analysis was adjusted for the confounding effect of including patients with a history of seizure prior to study inclusion.

RESULTS

A total of 454 patients received prophylactic AED whereas 333 were allocated to placebo or no treatment. Two RCTs and four retrospective studies were identified. The OR was 1.09 (95% CI 0.7 to 1.8, p=0.7, I²=5.6%, χ² p=0.5), indicating study consistency and no significant differences. An additional two RCTs and one retrospective study combined craniotomy and diagnostic biopsy, and were subgroup analysed-which supported no difference in odds for epilepsy.

CONCLUSIONS

A prophylactic effect of AED could not be demonstrated (nor rejected statistically). Levetiracetam was associated with less adverse effects than phenytoin. The potential harm of AED was not balanced by the potential prophylactic benefit. This study suggests that prophylactic AED should not be administered to prevent brain tumour-related epilepsy after craniotomy.

Levetiracetam

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