title: Perioperative seizure in patients with glioma is associated with longer hospitalization, higher readmission, and decreased overall survival.
abstract: OBJECTIVE Seizures are among the most common perioperative complications in patients undergoing craniotomy for brain tumor resection and have been associated with increased disease progression and decreased survival. Little evidence exists regarding the relationship between postoperative seizures and hospital quality measures, including length of stay (LOS), disposition, and readmission. The authors sought to address these questions by analyzing a glioma population over 15 years. METHODS A retrospective cohort study was used to evaluate the outcomes of patients who experienced a postoperative seizure. Patients with glioma who underwent craniotomy for resection between 1998 and 2013 were enrolled in the institutional tumor registry. Basic data, including demographics and comorbidities, were recorded in addition to hospitalization details and complications. Seizures were diagnosed by clinical examination, observation, and electroencephalography. The Student t-test and chi-square test were used to analyze differences in the means between continuous and categorical variables, respectively. Multivariate logistic and linear regression was used to compare multiple clinical variables against hospital quality metrics and survival figures, respectively. RESULTS In total, 342 patients with glioma underwent craniotomy for first-time resection. The mean age was 51.0 ± 17.3 years, 192 (56.1%) patients were male, and the median survival time for all grades was 15.4 months (range 6.2-24.0 months). High-grade glioma (Grade III or IV) was seen in 71.9% of patients. Perioperative antiepileptic drugs were administered to 88% of patients. Eighteen (5.3%) patients experienced a seizure within 14 days postoperatively, and 9 (50%) of these patients experienced first-time seizures. The mean time to the first postoperative seizure was 4.3 days (range 0-13 days). There was no significant association between tumor grade and the rate of perioperative seizure (Grade I, 0%; II, 7.0%; III, 6.1%; IV, 5.2%; p = 0.665). A single ictal episode occurred in 11 patients, while 3 patients experienced 2 seizures and 4 patients developed 3 or more seizures. Compared with their seizure-free counterparts, patients who experienced a perioperative seizure had an increased average hospital (6.8 vs 3.6 days, p = 0.032) and ICU LOS (5.4 vs 2.3 days; p < 0.041). Seventy-five percent of seizure-free patients were discharged home in comparison with 55.6% of seizure patients (p = 0.068). Patients with a postoperative seizure were significantly more likely to visit the emergency department within 90 days (44.4% vs 19.0%; OR 3.41 [95% CI 1.29-9.02], p = 0.009) and more likely to be readmitted within 90 days (50.0% vs 18.4%; OR 4.45 [95% CI 1.69-11.70], p = 0.001). In addition, seizure-free patients had a longer median overall survival (15.6 months [interquartile range 6.6-24.4 months] vs 3.0 months [interquartile range 1.0-25.0 months]; p = 0.013). CONCLUSIONS Patients with perioperative seizures following glioma resection required longer hospital and ICU LOS, were readmitted at higher rates than seizure-free patients, and experienced shorter overall survival. Biological and clinical factors that predispose to the development of seizures after glioma surgery portend a worse outcome. Efforts to identify these factors and reduce the risk of postoperative seizure should remain a priority among neurosurgical oncologists.
authors.affiliation: Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Dewan
authors.affiliation: Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Gabrielle A
authors.initials: GA
authors.lastname: White-Dzuro
authors.affiliation: Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Philip R
authors.initials: PR
authors.lastname: Brinson
authors.affiliation: Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Reid C
authors.initials: RC
authors.lastname: Thompson
authors.affiliation: Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Lola B
authors.initials: LB
authors.lastname: Chambless
mesh_terms: D001932:Brain Neoplasms / Q000150:complications* / Q000401:mortality / Q000601:surgery*; D015331:Cohort Studies; D003399:Craniotomy; D005260:Female; D005910:Glioma / Q000150:complications* / Q000401:mortality / Q000601:surgery*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012640:Seizures / Q000209:etiology*; D015996:Survival Rate
keywords: ACA = Affordable Care Act; AED = antiepileptic drug; ED = emergency department; EEG = electroencephalography; EOR = extent of resection; GTR = gross-total resection; IQR = interquartile range; KPS = Karnofsky Performance Scale; LOS = length of stay; NTR = near-total resection; STR = subtotal resection; glioma; length of stay; oncology; readmission; seizure; survival