title: The risk of hypotension and seizures in patients receiving prophylactic anti-epileptic drugs for supratentorial craniotomy.
abstract: BACKGROUND
  Perioperative seizure prophylaxis with antiepileptic drugs (AED) has been advocated in patients undergoing supratentorial craniotomy. The practice 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. Even short periods of hypotension during the operation can lead to acute kidney and myocardial injury. We retrospectively evaluated cardiovascular effects and tolerability of levetiracetam (LEV) alone, LEV and lacosamid (LCM) as compared to phenytoin (PHT).
  
  
  METHODS
  After IRB approval, the charts of individuals who underwent craniotomy from April 2007 to September 2011 were reviewed. Those receiving PHT were compared to those receiving LEV alone and LEV/LCM. The patient data included demographic, indication and procedure related data. The cumulative dose of norepinephrine (NET), atropine (ATR) and the change in systolic blood pressure during and after the administration of the AED were analyzed.
  
  
  RESULTS
  Five hundred thirty-eight patients were screened of which 122 were included for analysis. 40 patients with primary or secondary supratentorial brain tumors received LEV (19 female, 21 male; mean age 56 years), 41 patients received LEV/ LCM (16 female, 25 male; mean age 56 years) and 41 patients received PHT (15 female, 26 male; mean age 50 years). The commonest indications for craniotomy were glioblastoma (N.=14 vs. N.=12 vs. N.=15), meningiomas (N.=9 vs. N.=7 vs. N.=10), low-grade gliomas (N.=6 vs. N.=13 vs. N.=6) and brain metastases (N.=5 vs. N.=4 vs. N.=5). 1 LEV/LCM patient (2%) and 4 PHT patients (4.5%) had a seizure despite prophylaxis. Possible side effects were observed in 2 patients associated with PHT. 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 (P=0.001) and LEV/LCM (P≤0.0001) respectively. The mean cumulative doses of NET and ATR over the course of the operation did not differ significantly.
  
  
  CONCLUSIONS
  LEV alone and in combination with LCM for patients without and with symptomatic epilepsy as seizure prophylaxis provides a safe and feasible alternative to PHT. PHT was associated with an unfavorable drop in blood pressure during anesthesia and more adverse reactions.
authors.affiliation: Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany - julius.hoehne@ukr.de.
authors.forename: Julius
authors.initials: J
authors.lastname: Höhne
authors.affiliation: Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany.
authors.forename: Karl-Michael
authors.initials: KM
authors.lastname: Schebesch
authors.affiliation: Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Ott
authors.affiliation: Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany.
authors.forename: Alexander
authors.initials: A
authors.lastname: Brawanski
authors.affiliation: Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany.
authors.forename: Max
authors.initials: M
authors.lastname: Lange
mesh_terms: D000081:Acetamides / Q000009:adverse effects; D000328:Adult; D000927:Anticonvulsants / Q000009:adverse effects*; D001794:Blood Pressure / Q000187:drug effects; D003399:Craniotomy / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007022:Hypotension / Q000139:chemically induced* / Q000453:epidemiology; D000078334:Lacosamide; D000077287:Levetiracetam; D008297:Male; D008875:Middle Aged; D010672:Phenytoin / Q000009:adverse effects; D010889:Piracetam / Q000009:adverse effects / Q000031:analogs & derivatives; D065129:Pre-Exposure Prophylaxis / Q000379:methods; D012189:Retrospective Studies; D012640:Seizures / Q000517:prevention & control*; D015173:Supratentorial Neoplasms / Q000601:surgery
chemical_list: D000081:Acetamides; D000927:Anticonvulsants; D000077287:Levetiracetam; D000078334:Lacosamide; D010672:Phenytoin; D010889:Piracetam