Risk of epilepsy in surgical patients undergoing general or neuraxial anaesthesia

Epilepsy Risk Associated With the Receipt of General Anesthesia Relative to Neuraxial Anesthesia: A Retrospective Cohort Study

BACKGROUND AND OBJECTIVES

Evidence suggests that the receipt of general anesthesia may be associated with an increased risk of epilepsy compared with neuraxial (i.e., spinal or epidural) anesthesia. Our study objective was to estimate the risk of developing new-onset epilepsy associated with the receipt of general anesthesia relative to neuraxial anesthesia.

METHODS

We conducted a population-based retrospective cohort study using linked health administrative databases in Ontario, Canada. Participants who underwent an eligible surgical procedure with general or neuraxial anesthesia between April 1, 2007, and March 31, 2015, were included and followed for up to 5 years. Eligible surgical procedures included gynecologic, lower extremity, peripheral vascular, and urologic procedures that could be performed using general or neuraxial anesthesia. Patients with epilepsy or epilepsy risk factors in the 10 years before their surgical procedure were excluded. We used inverse probability of treatment weighting to control for confounding and Fine-Gray subdistribution models to estimate the hazard ratio for epilepsy, accounting for the competing risk of death.

RESULTS

The final sample included 100,547 patients who received general anesthesia and 76,644 patients who received neuraxial anesthesia. After weighting, the general and neuraxial anesthesia cohorts comprised 64.8% and 63.0% of women and the mean ages were 56.0 and 56.8 years, respectively. The estimated weighted event rates of epilepsy were 48.8 and 35.5 per 100,000 person-years for general and neuraxial anesthesia cohorts, respectively. The hazard ratio (HR) for epilepsy associated with general anesthesia was 0.61 at time zero (95% CI 0.34-1.07). However, there was evidence that risk changed over the five-year follow-up period (time interaction HR = 1.36, 95% CI 1.12-1.64). This led to a significantly increased risk of epilepsy associated with general anesthesia after approximately 3 years.

DISCUSSION

The effects of general anesthesia may take multiple years to become significantly associated with an increased risk of epilepsy. However, our findings are likely affected by other factors, such as unmeasured differences between the anesthesia cohorts, types of surgical procedures, and the occurrence of epilepsy risk factors during follow-up. Future research should explore whether there is effect modification between specific surgical procedures and control for the onset of epilepsy risk factors after anesthesia receipt.

Efficacy study of neuronavigation-assisted stereotactic drilling of urokinase drainage versus craniotomy in the treatment of massive intracerebral haemorrhage in elderly patientsa

To evaluate the efficacy of neuronavigation-assisted stereotactic drilling drainage compared with that of craniotomy in the treatment of massive intracerebral haemorrhage (ICH) in elderly patients. This was a randomized, controlled, blind endpoint clinical study. Elderly patients with massive ICH treated at our neurosurgery department, without the formation of brain herniation preoperatively, all underwent neurosurgical intervention. Patients were randomly assigned to two groups: the minimally invasive surgery (MIS) group, which received neuronavigation-assisted stereotactic drilling drainage, and the craniotomy haematoma removal surgery (CHRS) group. Patient characteristics, surgical anaesthesia methods, surgery duration, intraoperative bleeding volume, duration of ICU stay duration of hospital stay, complications, and modified Rankin scale (mRS) scores at 90 days posttreatment were compared between the two groups. Statistical analysis was performed on the collected data. A total of 67 patients were randomly assigned, with 33 (49.25%) in the MIS group and 34 (50.75%) in the CHRS group. Compared with the CHRS group, the MIS group had advantages, including the use of local anaesthesia, shorter surgery duration, less intraoperative bleeding, shorter ICU stay, and fewer complications (P < 0.05). The MIS group had a significantly improved patient prognosis at 90 days (mRS 0-3). However, there were no significant differences in hospital stay or 90-day survival rate between the two groups (P > 0.05). For elderly patients with massive ICH without brain herniation, stereotactic drilling drainage is a simple surgical procedure that can be performed under local anaesthesia. Patients treated with this approach seem to have better outcomes than those treated with craniotomy. In clinical practice, neuronavigation-assisted stereotactic drilling drainage is recommended for surgical treatment in elderly patients with massive ICH without brain herniation.Clinical trial registration number: NCT04686877.

Maternal sevoflurane exposure increases the epilepsy susceptibility of adolescent offspring by interrupting interneuron development

BACKGROUND

Exposure to general anesthesia influences neuronal functions during brain development. Recently, interneurons were found to be involved in developmental neurotoxicity by anesthetic exposure. But the underlying mechanism and long-term consequences remain elusive.

METHODS

Pregnant mice received 2.5% sevoflurane for 6-h on gestational day 14.5. Pentylenetetrazole (PTZ)-induced seizure, anxiety- and depression-like behavior tests were performed in 30- and 60-day-old male offspring. Cortical interneurons were labeled using Rosa26-EYFP/-; Nkx2.1-Cre mice. Immunofluorescence and electrophysiology were performed to determine the cortical interneuron properties. Q-PCR and in situ hybridization (ISH) were performed for the potential mechanism, and the finding was further validated by in utero electroporation (IUE).

RESULTS

In this study, we found that maternal sevoflurane exposure increased epilepsy susceptibility by using pentylenetetrazole (PTZ) induced-kindling models and enhanced anxiety- and depression-like behaviors in adolescent offspring. After sevoflurane exposure, the highly ordered cortical interneuron migration was disrupted in the fetal cortex. In addition, the resting membrane potentials of fast-spiking interneurons in the sevoflurane-treated group were more hyperpolarized in adolescence accompanied by an increase in inhibitory synapses. Both q-PCR and ISH indicated that CXCL12/CXCR4 signaling pathway downregulation might be a potential mechanism under sevoflurane developmental neurotoxicity which was further confirmed by IUE and behavioral tests. Although the above effects were obvious in adolescence, they did not persist into adulthood.

CONCLUSIONS

Our findings demonstrate that maternal anesthesia impairs interneuron migration through the CXCL12/CXCR4 signaling pathway, and influences the interneuron properties, leading to the increased epilepsy susceptibility in adolescent offspring. Our study provides a novel perspective on the developmental neurotoxicity of the mechanistic link between maternal use of general anesthesia and increased susceptibility to epilepsy.

Chairside oral prophylaxis for people with profound intellectual or multiple disabilities-a retrospective feasibility study

OBJECTIVES

People with severe intellectual or multiple disabilities (PIMD) have been receiving dental care in a specialized unit offering special care dentistry. For most of these adult patients, the initial consultation is complaint driven. In addition, the limited ability to cooperate due to their disabilities often means that dental treatment for these patients is usually carried out under general anesthesia (GA). Chairside treatment attempts are the exception rather than the rule. This retrospective study evaluated whether consistent practice of behavioral management principles and techniques embedded in a specific dental environment enables successful dental treatment of PIMD.

MATERIALS AND METHODS

The feasibility of chairside dental prophylaxis in PIMD (n=36) was analyzed: specific behavioral management techniques were applied, and professional tooth cleaning (PTC) was performed in the dental chair. Clinical data obtained from medical records and a questionnaire were analyzed.

RESULTS

All patients had severe intellectual or multiple disabilities and had previously undergone at least one dental treatment under GA. Of these patients, 55.6% never had their teeth professionally cleaned before. Applying different behavioral techniques, all patients were compliant with receiving PTC in the dental chair.

CONCLUSIONS

An individualized and disability-specific treatment strategy using various noninvasive and nonpharmacological behavioral guidance techniques resulted in a higher compliance rate in PIMD, which allowed chairside PTC and reduced the need for treatment under GA.

CLINICAL RELEVANCE

Consistent implementation of various behavioral guidance techniques and communication strategies in a supportive environment enabled all patients to receive chairside PTC and be involved in a lifelong recall program.