levetiracetam and Postoperative-Complications

This is an updated version of the Cochrane Review previously published in 2018. The incidence of seizures following supratentorial craniotomy for non-traumatic pathology has been estimated to be between 15% to 20%; however, the risk of experiencing a seizure appears to vary from 3% to 92% over a five-year period. Postoperative seizures can precipitate the development of epilepsy; seizures are most likely to occur within the first month of cranial surgery. The use of antiepileptic drugs (AEDs) administered pre- or postoperatively to prevent seizures following cranial surgery has been investigated in a number of randomised controlled trials (RCTs).. To determine the efficacy and safety of AEDs when used prophylactically in people undergoing craniotomy and to examine which AEDs are most effective.. For the latest update we searched the following databases on 29 September 2019: Cochrane Epilepsy Group Specialized Register, CENTRAL, MEDLINE, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP). We did not apply any language restrictions.. We included RCTs of people with no history of epilepsy who were undergoing craniotomy for either therapeutic or diagnostic reasons. We included trials with adequate randomisation methods and concealment; these could either be blinded or unblinded parallel trials. We did not stipulate a minimum treatment period, and we included trials using active drugs or placebo as a control group.. Three review authors (JW, JG, YD) independently selected trials for inclusion, extracted data and assessed risk of bias. We resolved any disagreements through discussion. Outcomes investigated included the number of participants experiencing seizures (early (occurring within first week following craniotomy), and late (occurring after first week following craniotomy)), the number of deaths and the number of people experiencing disability and adverse effects. Due to the heterogeneous nature of the trials, we did not combine data from the included trials in a meta-analysis; we presented the findings of the review in narrative format. Visual comparisons of outcomes are presented in forest plots.. We included 10 RCTs (N = 1815), which were published between 1983 and 2015. Three trials compared a single AED (phenytoin) with placebo or no treatment. One, three-armed trial compared two AEDs (phenytoin, carbamazepine) with no treatment. A second three-armed trial compared phenytoin, phenobarbital with no treatment. Of these five trials comparing AEDs with placebo or no treatment, two trials reported a statistically significant advantage for AED treatment compared to controls for early seizure occurrence; all other comparisons showed no clear or statistically significant differences between AEDs and control treatment. None of the trials that were head-to-head comparisons of AEDs (phenytoin versus sodium valproate, phenytoin versus phenobarbital, levetiracetam versus phenytoin, zonisamide versus phenobarbital) reported any statistically significant differences between treatments for either early or late seizure occurrence. Only five trials reported incidences of death. One trial reported statistically significantly fewer deaths in the carbamazepine and no-treatment groups compared with the phenytoin group after 24 months of treatment, but not after six months of treatment. Incidences of adverse effects of treatment were poorly reported; however, three trials did show that significantly more adverse events occurred on phenytoin compared to valproate, placebo, or no treatment. No trials reported any results relating to functional outcomes such as disability. We considered the evidence to be of low certainty for all reported outcomes due to methodological issues and variability of comparisons made in the trials.. There is limited, low-certainly evidence to suggest that AED treatment administered prophylactically is either effective or not effective in the prevention of postcraniotomy (early or late) seizures. The current evidence base is limited due to the different methodologies employed in the trials and inconsistencies in the reporting of outcomes including deaths and adverse events. Further evidence from good-quality, contemporary trials is required in order to assess the clinical effectiveness of prophylactic AED treatment compared to placebo or no treatment, or other AEDs in preventing postcraniotomy seizures in this select group of patients.

Topics: Anticonvulsants; Carbamazepine; Craniotomy; Humans; Isoxazoles; Levetiracetam; Phenobarbital; Phenytoin; Piracetam; Postoperative Complications; Randomized Controlled Trials as Topic; Seizures; Valproic Acid; Zonisamide

OBJECTIVEDe novo seizure following craniotomy (DSC) for nontraumatic pathology may adversely affect medical and neurological outcomes in patients with no history of seizures who have undergone craniotomies. Antiepileptic drugs (AEDs) are commonly used prophylactically in patients undergoing craniotomy; however, evidence supporting this practice is limited and mixed. The authors aimed to collate the available evidence on the efficacy and tolerability of levetiracetam monotherapy and compare it with that of the classic AED, phenytoin, for DSC.METHODSPubMed, Embase, Web of Science, and the Cochrane Library were searched for studies that compared levetiracetam with phenytoin for DSC prevention. Inclusion criteria were adult patients with no history of epilepsy who underwent craniotomy with prophylactic usage of phenytoin, a comparator group with levetiracetam treatment as the main treatment difference between the two groups, and availability of data on the numbers of patients and seizures for each group. Patients with brain injury and previous seizure history were excluded. DSC occurrence and adverse drug reaction (ADR) were evaluated. Seizure occurrence was calculated using the Peto odds ratio (POR), which is the relative effect estimation method of choice for binary data with rare events.RESULTSData from 7 studies involving 803 patients were included. The DSC occurrence rate was 1.26% (4/318) in the levetiracetam cohort and 6.60% (32/485) in the phenytoin cohort. Meta-analysis showed that levetiracetam is significantly superior to phenytoin for DSC prevention (POR 0.233, 95% confidence interval [CI] 0.117-0.462, p < 0.001). Subgroup analysis demonstrated that levetiracetam is superior to phenytoin for DSC due to all brain diseases (POR 0.129, 95% CI 0.039-0.423, p = 0.001) and tumor (POR 0.282, 95% CI 0.117-0.678, p = 0.005). ADRs in the levetiracetam group were cognitive disturbance, thrombophlebitis, irritability, lethargy, tiredness, and asthenia, whereas rash, anaphylaxis, arrhythmia, and hyponatremia were more common in the phenytoin group. The overall occurrence of ADR in the phenytoin (34/466) and levetiracetam (26/432) groups (p = 0.44) demonstrated no statistically significant difference in ADR occurrence. However, the discontinuation rate of AEDs due to ADR was 53/297 in the phenytoin group and 6/196 in the levetiracetam group (POR 0.266, 95% CI 0.137-0.518, p < 0.001).CONCLUSIONSLevetiracetam is superior to phenytoin for DSC prevention for nontra

Topics: Anticonvulsants; Craniotomy; Humans; Levetiracetam; Phenytoin; Postoperative Complications; Randomized Controlled Trials as Topic; Seizures; Treatment Outcome

This is an updated version of the Cochrane Review previously published in Issue 3, 2015.The incidence of seizures following supratentorial craniotomy for non-traumatic pathology has been estimated to be between 15% to 20%; however, the risk of experiencing a seizure appears to vary from 3% to 92% over a five-year period. Postoperative seizures can precipitate the development of epilepsy; seizures are most likely to occur within the first month of cranial surgery. The use of antiepileptic drugs (AEDs) administered pre- or postoperatively to prevent seizures following cranial surgery has been investigated in a number of randomised controlled trials (RCTs).. To determine the efficacy and safety of AEDs when used prophylactically in people undergoing craniotomy and to examine which AEDs are most effective.. For the latest update we searched the following databases on 26 June 2017: Cochrane Epilepsy Group Specialized Register, the CENTRAL, MEDLINE, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP). We did not apply any language restrictions.. We included RCTs of people with no history of epilepsy who were undergoing craniotomy for either therapeutic or diagnostic reasons. We included trials with adequate randomisation methods and concealment; these could either be blinded or unblinded parallel trials. We did not stipulate a minimum treatment period, and we included trials using active drugs or placebo as a control group.. Three review authors (JW, JG, YD) independently selected trials for inclusion and performed data extraction and risk of bias assessments. We resolved any disagreements through discussion. Outcomes investigated included the number of participants experiencing seizures (early (occurring within first week following craniotomy), and late (occurring after first week following craniotomy)), the number of deaths and the number of people experiencing disability and adverse effects. Due to the heterogeneous nature of the trials, we did not combine data from the included trials in a meta-analysis; we presented the findings of the review in narrative format. Visual comparisons of outcomes are presented in forest plots.. We included 10 RCTs (N = 1815), which were published between 1983 and 2015. Three trials compared a single AED (phenytoin) with placebo or no treatment. One three-armed trial compared two AEDs (phenytoin, carbamazepine) with no treatment. A second three-armed trial compared phenytoin, phenobarbital with no treatment. Of these five trials comparing AEDs with placebo or no treatment, two trials reported a statistically significant advantage for AED treatment compared to controls for early seizure occurrence; all other comparisons showed no clear or statistically significant differences between AEDs and control treatment. None of the trials that were head-to-head comparisons of AEDs (phenytoin versus sodium valproate, phenytoin versus phenobarbital, levetiracetam versus phenytoin, zonisamide versus phenobarbital) reported any statistically significant differences between treatments for either early or late seizure occurrence.Incidences of death were reported in only five trials. One trial reported statistically significantly fewer deaths in the carbamazepine and no-treatment groups compared with the phenytoin group after 24 months of treatment, but not after six months of treatment. Incidences of adverse effects of treatment were poorly reported; however, three trials did show that significantly more adverse events occurred on phenytoin compared to valproate, placebo, or no treatment. No trials reported any results relating to functional outcomes such as disability.We considered the evidence to be of low quality for all reported outcomes due to methodological issues and variability of comparisons made in the trials.. There is limited, low-quality evidence to suggest that AED treatment administered prophylactically is either effective or not effective in the prevention of postcraniotomy (early or late) seizures. The current evidence base is limited due to the different methodologies employed in the trials and inconsistencies in the reporting of outcomes including deaths and adverse events. Further evidence from good-quality, contemporary trials is required in order to assess the clinical effectiveness of prophylactic AED treatment compared to placebo or no treatment, or other AEDs in preventing postcraniotomy seizures in this select group of patients.

Topics: Anticonvulsants; Carbamazepine; Craniotomy; Humans; Isoxazoles; Levetiracetam; Phenobarbital; Phenytoin; Piracetam; Postoperative Complications; Randomized Controlled Trials as Topic; Seizures; Valproic Acid; Zonisamide

On the basis of the relevance of adequate epilepsy treatment (antiepileptic drugs, surgery and vagus nerve stimulation) for people with intellectual disabilities, all articles, published from the beginning of 2005 to March 2006 and searched by MEDLINE, on this topic were reviewed.. On pharmacological treatment of epilepsy in people with intellectual disabilities, there were two articles on topiramate and one on levetiracetam. Two studies described the effect of surgical interventions, one of epilepsy surgery in the narrow sense and one of vagus nerve stimulation. Two papers were published on clinical conditions and therapeutic aspects of Angelman syndrome. They highlight the importance of gamma-aminobutyric acidergic mechanism in Angelman syndrome and the antiepileptic drug effects in this syndrome.. A contradiction exists between the relevance of epilepsy treatment in people with intellectual disabilities and the small number of published studies on pharmacological treatment. Some of the reasons are addressed and some alternatives are proposed.

Topics: Anticonvulsants; Brain; Electric Stimulation Therapy; Epilepsy; Fructose; Humans; Intellectual Disability; Levetiracetam; Neurosurgical Procedures; Piracetam; Postoperative Complications; Topiramate; Vagus Nerve

Phenytoin (PHT) is routinely used for seizure prophylaxis in patients with brain tumours during and after craniotomy, despite incomplete evidence. We performed a prospective, randomised study to investigate the significance of prophylactic use of levetiracetam (LEV), in comparison with PHT, for patients with supratentorial tumours in the perioperative period.. Patients were randomised to receive LEV, 500 mg/body every 12 h until postoperative day 7, or PHT, 15-18 mg/kg fosphenytoin followed by 125 mg PHT every 12 h until postoperative day 7. The primary end point was the occurrence of seizures, and secondary end points included the occurrence of haematological and non-haematological adverse events.. One hundred and forty-six patients were randomised to receive LEV (n=73) or PHT (n=73). The incidence of seizures was significantly less in the LEV group (1.4%) compared with the PHT group (15.1%, p=0.005), suggesting benefit of LEV over PHT. The observed OR for being seizure free in the LEV prophylaxis group relative to the PHT group was 12.77 (95% CI 2.39 to 236.71, p=0.001). In a subgroup analysis of patients who did not have seizures before craniotomy, similar results were demonstrated: the incidence of seizures was 1.9% (LEV) and 13.8% (PHT, p=0.034), and OR was 8.16 (95% CI 1.42 to 154.19, p=0.015). LEV was completed in all cases, although PHT was withdrawn in five patients owing to liver dysfunction (1), skin eruption (2) and atrial fibrillation (2).. Prophylactic use of LEV in the perioperative period is recommended because it is safe and significantly reduces the incidence of seizures in this period.. UMIN13971.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticonvulsants; Brain Neoplasms; Cohort Studies; Craniotomy; Female; Humans; Levetiracetam; Male; Middle Aged; Neurosurgical Procedures; Phenytoin; Piracetam; Postoperative Complications; Prospective Studies; Seizures; Treatment Outcome; Young Adult

Seizures may occur after orthotopic liver transplantation. Antiepileptic drugs (AEDs) are used to treat these seizures, but the immunosuppressant regimen also may be altered. Levetiracetam is an attractive treatment because of its efficacy, lack of hepatic enzyme induction, and its rapid attainment of serum levels. Treatment with levetiracetam is efficacious, and levetiracetam-treated patients require significantly lower doses of immunosuppressant medications to achieve an equivalent antirejection effect.

Topics: Anticonvulsants; Cytochrome P-450 Enzyme System; Dose-Response Relationship, Drug; Drug Interactions; Female; Humans; Immunosuppressive Agents; Levetiracetam; Liver; Liver Transplantation; Male; Phenytoin; Piracetam; Postoperative Complications; Retrospective Studies; Seizures; Treatment Outcome

Chronic post-hypoxic myoclonus is a condition in which the predominant clinical picture is myoclonus following hypoxic brain damage, usually due to cardiorespiratory arrest. It is a condition that is usually treated with antiepileptic drugs, in most cases with a modest clinical response.. We report the case of a patient who started with jerking movements, compatible with myoclonus in the four limbs and the face the day after recovering from a cardiorespiratory arrest. An electroencephalogram was performed during which the myoclonias were recorded with no electrical correlates. During admission, and in successive visits after discharge, different antiepileptic treatments were tried for the myoclonias, which were refractory and affected the patient's quality of life. Two years after onset, treatment with perampanel up to a dose of 4 mg was initiated and the patient reported a significant clinical improvement, as evidenced in the visits.. Perampanel may be an effective alternative for the treatment of myoclonias in patients with chronic post-hypoxic myoclonus.. Respuesta a perampanel en un paciente con mioclono posthipóxico crónico.. Introducción. El mioclono posthipóxico crónico es un cuadro cuya clínica predominante son las mioclonías que acontecen tras un daño cerebral hipóxico, generalmente por parada cardiorrespiratoria. Es una entidad que se trata generalmente con fármacos antiepilépticos, con una modesta respuesta clínica en la mayoría de los casos. Caso clínico. Paciente que comienza con movimientos de sacudidas, compatibles con mioclonías de las cuatro extremidades y faciales al día siguiente de una parada cardiorrespiratoria recuperada. Se realizó un electroencefalograma durante el cual se registraron las mioclonías sin presentar correlato eléctrico. Durante el ingreso, y en sucesivas visitas tras el alta, se probaron diferentes tratamientos antiepilépticos para las mioclonías, que fueron refractarias y comportaron una afectación de la calidad de vida del paciente. Tras dos años de evolución, se inició tratamiento con perampanel hasta una dosis de 4 mg y el paciente refirió una mejoría clínica importante, evidenciada en consultas. Conclusiones. El perampanel puede suponer una alternativa eficaz para el tratamiento de las mioclonías en pacientes con mioclono posthipóxico crónico.

Topics: Anticonvulsants; Carcinoma, Papillary; Clonazepam; Drug Therapy, Combination; Electroencephalography; Heart Arrest; Humans; Hypoxia, Brain; Levetiracetam; Male; Middle Aged; Myoclonus; Nitriles; Postoperative Complications; Pyridones; Seizures; Thyroid Neoplasms; Thyroidectomy; Valproic Acid

BACKGROUND Phenytoin is an antiepileptic drug that is usually prescribed as a prevention treatment for tonic-clonic seizures or partial seizures, and as a prophylaxis for the neurosurgical related seizures. Phenytoin administration has several drawbacks; one drawback phenytoin-induced thrombocytopenia, which is a rare and significant adverse event. We report a rare adverse event after phenytoin prophylaxis therapy after a brain tumor debulking surgery, which resulted in severe unpredicted thrombocytopenia. CASE REPORT A 40-year-old male with no known health problems started to have an on/off headaches and loss of memory. Clinical investigations revealed a right frontal brain lesion. On the first day of admission, the patient was managed on neurosurgical seizure prophylaxis therapy of 100 mg intravenous phenytoin every 8 hours and 4 mg oral dexamethasone every 6 hours. On the fifth day of hospital admission, the patient underwent tumor debulking surgery. Twenty-four hours post-surgery, the patient's platelet level dropped to 26×10⁹/L. Severe thrombocytopenia was managed first by transfusion of 17 units of platelets and by cessation of intravenous phenytoin plus the starting of 500 mg levetiracetam orally twice daily. Further management included infusion of 34 grams (0.4 g/kg) intravenous immunoglobulin (IVIG) over 5 days. Five days later, the patient gradually recovered with a platelet count of 239×10⁹/L. CONCLUSIONS Phenytoin-induced thrombocytopenia is considered a rare event, but it has life-threatening consequences. The first and cornerstone management of this event is the cessation of phenytoin, followed by consideration of appropriate management based on the level of thrombocytopenia severity, and avoiding concomitant therapy of phenytoin and the use of dexamethasone as neurosurgical-related seizure prophylaxis.

Topics: Adult; Anticonvulsants; Brain Neoplasms; Cytoreduction Surgical Procedures; Humans; Immunoglobulins, Intravenous; Levetiracetam; Male; Phenytoin; Postoperative Complications; Thrombocytopenia

To compare the safety and efficacy of phenobarbital and levetiracetam in a cohort of neonates with seizures following cardiac surgery.. We performed a retrospective single-center study of consecutive neonates with electrographically confirmed seizures managed with antiseizure medication after cardiac surgery from June 15, 2012 to December 31, 2018. We compared the safety and efficacy of phenobarbital and levetiracetam as first-line therapy.. First-line therapy was phenobarbital in 31 neonates and levetiracetam in 22 neonates. Phenobarbital was associated with more adverse events (P = .006). Eight neonates (14%) experienced an adverse event related to phenobarbital use, including seven with hypotension and one with respiratory depression. No adverse events were reported with levetiracetam use. The cessation of electrographic seizures was similar in both groups, including 18 neonates (58%) with seizure cessation after phenobarbital and 12 neonates (55%) with seizure cessation after levetiracetam (P = 1.0). The combined cessation rates of phenobarbital and levetiracetam when used as first- or second-line therapy were 58% and 47%, respectively (P = .47).. Phenobarbital was associated with more adverse events than levetiracetam, and the two drugs were equally but incompletely effective in treating electrographically confirmed seizures in neonates following cardiac surgery. Given its more acceptable safety profile and potential noninferiority, levetiracetam may be a reasonable option for first-line therapy for treatment of seizures in this population. Further prospective studies are needed to confirm these results.

Topics: Anticonvulsants; Cardiac Surgical Procedures; Female; Humans; Infant, Newborn; Levetiracetam; Male; Phenobarbital; Postoperative Complications; Retrospective Studies; Seizures

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.

Topics: Adult; Aged; Anticonvulsants; Cohort Studies; Craniotomy; Female; Humans; Levetiracetam; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Seizures; Supratentorial Neoplasms

Cranioplasty is a relatively simple and straightforward intervention; however, it is associated with a high incidence of postoperative seizures. Postcranioplasty seizures, especially early seizures, are common and associated with poor outcomes and longer hospital stays. Protocols for preventing and managing early seizures have not been well established.. The medical records of 595 patients who underwent cranioplasty were retrospectively reviewed. Of these patients, 259 had preexisting seizures and 336 had no seizures before cranioplasty. Prophylactic antiepileptic drugs (AEDs) were administered to patients who had no seizures before cranioplasty for 1 week, whereas an advanced AED regimen was administered to patients with preexisting seizures. Subsequently, clinical characteristics, occurrence of recurrent seizures, early seizures, and postoperative complications were analyzed.. Our previous study showed positive results for prophylaxis in new-onset early seizures. In the patients with preexisting seizures, 46.7% of the patients (121/259) experienced recurrent seizures after cranioplasty and 17.4% of the patients (45/259) experienced early recurrent seizures within 1 week of their operation. In the group who received the advanced AEDs, early recurrent seizures were significantly reduced to 8.7% compared with the regular group (20.5%; P = 0.027). Younger age and preoperative hydrocephalus engendered a higher risk of recurrent seizures. The number of previous craniotomies was observed to have a trend of increasing early recurrent seizures.. Cranioplasty is associated with a high incidence of postoperative seizures. Our management protocol for postcranioplasty seizures includes seizure prophylaxis and advanced use of AEDs, which can reduce the occurrence of early seizures.

Topics: Adult; Anticonvulsants; Clinical Protocols; Decompressive Craniectomy; Drug Administration Schedule; Drug Therapy, Combination; Female; Hospitalization; Humans; Levetiracetam; Male; Phenytoin; Postoperative Complications; Recurrence; Retrospective Studies; Seizures; Skull; Treatment Outcome; Valproic Acid

To report the incidence of postattenuation seizures (PAS) in dogs that underwent single congenital extrahepatic portosystemic shunt (cEHPSS) attenuation and to compare incidence of PAS in dogs that either did or did not receive prophylactic treatment with levetiracetam (LEV).. Multi-institutional retrospective study.. Nine hundred forty dogs.. Medical records were reviewed to identify dogs that underwent surgical attenuation of a single cEHPSS from January 2005 through July 2017 and developed PAS within 7 days postoperatively. Dogs were divided into 3 groups: no LEV (LEV-); LEV at ≥15 mg/kg every 8 hours for ≥24 hours preoperatively or a 60 mg/kg intravenous loading dose perioperatively, followed by ≥15 mg/kg every 8 hours postoperatively (LEV1); and LEV at <15 mg/kg every 8 hours, for <24 hours preoperatively, or continued at <15 mg/kg every 8 hours postoperatively (LEV2).. Seventy-five (8.0%) dogs developed PAS. Incidence of PAS was 35 of 523 (6.7%), 21 of 188 (11.2%), and 19 of 228 (8.3%) in groups LEV-, LEV1, and LEV2, respectively. This difference was not statistically significant (P = .14). No differences between groups of dogs that seized with respect to investigated variables were identified.. The overall incidence of PAS was low (8%). Prophylactic treatment with LEV according to the protocols that were investigated in our study was not associated with a reduced incidence of PAS.. Prophylactic treatment with LEV does not afford protection against development of PAS. Surgically treated dogs should continue to be monitored closely during the first 7 days postoperatively for seizures.

Topics: Administration, Intravenous; Animals; Anticonvulsants; Dog Diseases; Dogs; Female; Incidence; Levetiracetam; Male; Portal System; Postoperative Complications; Postoperative Period; Retrospective Studies; Seizures; Vascular Malformations

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

Topics: Aged; Anticonvulsants; Blindness; Brain Neoplasms; Electroencephalography; Epilepsies, Partial; Female; Humans; Levetiracetam; Lumbar Vertebrae; Occipital Lobe; Postoperative Complications; Skull Base; Spinal Stenosis; Status Epilepticus

Levetiracetam may induce serious behavioral disturbances, especially after surgical resection of frontal lobe low-grade glioma. Two patients, treated with levetiracetam, developed serious psychiatric complications postoperatively which completely resolved after switching to valproate. We aim to create awareness for this serious but reversible adverse effect of levetiracetam in this specific patient category.

Topics: Anticonvulsants; Brain Neoplasms; Craniotomy; Epilepsy; Frontal Lobe; Humans; Levetiracetam; Magnetic Resonance Imaging; Male; Mental Disorders; Middle Aged; Oligodendroglioma; Piracetam; Postoperative Complications; Valproic Acid

Anticonvulsant drugs are frequently given after craniotomy. Phenytoin (PHT) is the most commonly used agent; levetiracetam (LEV) is a new anticonvulsant drug with fewer side effects. To compare the incidence of seizures in patients receiving either prophylactic PHT or LEV perioperatively, 971 patients undergoing a craniotomy were analysed retrospectively during a 2-year period. PHT was used routinely and LEV was administered when PHT was contraindicated. Seizures documented during the first 7 days after craniotomy were considered. A total of 235 patients were treated with an antiepileptic drug: 81 patients received LEV, and 154 patients, PHT. Two patients receiving LEV (2.5%) and seven receiving PHT (4.5%) had a seizure despite this treatment. No patient had a documented side effect or drug interaction. The data show that LEV may be an alternative option in patients with contraindications to PHT.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Brain Neoplasms; Child; Contraindications; Craniotomy; Female; Humans; Levetiracetam; Male; Middle Aged; Phenytoin; Piracetam; Postoperative Complications; Retrospective Studies; Seizures; Young Adult

To study the prognostic implications of antiepileptic drug (AED) use on seizure freedom following temporal lobe resections for intractable epilepsy.. Seizure outcome implications of epilepsy characteristics and AED use were studied in patients who underwent temporal lobectomy patients at the Cleveland Clinic between September 1995 and December 2006. Survival analysis and multivariate regression with Cox proportional hazard modeling were used. Complete seizure freedom was defined as a favorable outcome.. Records of 312 patients were analyzed (mean ± standard deviation follow-up 3.5 ± 1.7 years). The estimated probability of complete seizure freedom was 69% at 12 months (95% confidence interval [CI] 66-72%), and 48% at 36 months (95% CI 45-52%). The mean number of AEDs used per patient at the time of surgery was 1.78 (range 1-4), dropping to 1.02 at last follow-up (range 0-4). Following multivariate analysis, a lower preoperative seizure frequency and perioperative use of levetiracetam predicted a favorable outcome (risk ratio [RR] 0.62, 95% CI 0.43-0.89, and RR = 0.57, 95% CI 0.39-0.83, respectively), whereas nonspecific pathology (RR 1.71, 95% CI 1.15-2.47) and a higher number of AEDs used at the time of surgery correlated with higher rates of seizure recurrence (whole-model log-rank test p-value < 0.0001). Better outcomes within the levetiracetam group were seen despite a higher proportion of several poor prognostic indicators within this patient group, and started as early as 4 months after surgery, gradually increasing to a 15-20% survival advantage by 5 years. No similar outcome correlations were identified with another AED.. AED use may be a potential new modifiable seizure-outcome predictor after temporal lobectomy. This possible prognostic indicator is discussed in light of proposed seizure recurrence mechanisms.

Topics: Adolescent; Adult; Aged; Anterior Temporal Lobectomy; Anticonvulsants; Child; Child, Preschool; Epilepsy; Female; Humans; Levetiracetam; Longitudinal Studies; Magnetic Resonance Imaging; Male; Middle Aged; Piracetam; Positron-Emission Tomography; Postoperative Complications; Recurrence; Retrospective Studies; Seizures; Statistics, Nonparametric; Survival Analysis; Treatment Outcome; Young Adult

Topics: Anticonvulsants; Bacteriuria; Diagnosis, Differential; Diffusion Magnetic Resonance Imaging; Electroencephalography; Epilepsies, Partial; Facial Paralysis; Hemiplegia; Humans; Hydrocephalus; Levetiracetam; Male; Meningitis, Listeria; Middle Aged; Piracetam; Postoperative Complications; Status Epilepticus; Stroke; Ventriculoperitoneal Shunt

Topics: Anticonvulsants; Cardiovascular Surgical Procedures; Child, Preschool; Female; Heart Defects, Congenital; Humans; Levetiracetam; Piracetam; Postoperative Complications; Seizures; Stevens-Johnson Syndrome

Efficacy and tolerability of levetiracetam (LEV) as perioperative seizure prophylaxis in supratentorial brain tumor patients were retrospectively studied. Between February 2007 and April 2009 in a single institution, 78 patients with primary or secondary supratentorial brain tumors [40 female, 38 male; mean age 57 years, from 27 to 89 years; gliomas in 42 patients (53.8%), brain metastases in 17 (21.8%), meningiomas in 16 (20.5%), 1 primary central nervous system (CNS) lymphoma patient, and 2 patients with radiation necrosis] received between 1,000 mg and 3,000 mg LEV perioperatively. Preoperatively, 30 patients had experienced seizures (38.5%), most commonly glioma patients (47.6%), but also meningioma patients (31.3%) or patients with brain metastases (23.5%). No more seizures occurred in patients receiving 1-3 g LEV preoperatively. Within the first week postoperatively, a single seizure occurred in two patients (2.6%). At the end of the follow-up period (mean 10.5 months, range 0-31 months), 71 of the 78 patients (91%) were seizure free and 21 (26%) patients were not taking antiepileptic drugs. We observed side-effects in five patients (6.4%), including non-tumor-associated progressive somnolence in three patients (1.5 g, 1.5 g, and 2 g LEV daily) and reactive psychosis in two patients (1 and 1.5 g LEV daily), regressing after dose reduction. Perioperative LEV in supratentorial brain tumor patients was well tolerated. Compared with the literature, it resulted in low (2.6%) [corrected] seizure frequency in the early postoperative period. Additionally, its advantage of lacking cytochrome P450 enzyme induction allowed early initiation of effective postoperative chemotherapy in malignant glioma patients.

Topics: Adult; Aged; Aged, 80 and over; Anticonvulsants; Female; Humans; Levetiracetam; Male; Middle Aged; Neurosurgical Procedures; Perioperative Period; Piracetam; Postoperative Complications; Retrospective Studies; Seizures; Supratentorial Neoplasms

Non-convulsive status epilepticus (NCSE) is an underdiagnosed clinical entity in which electrical seizures occur with subtle or no overt clinical manifestations. It can cause delayed recovery from anesthesia and constitutes an important differential diagnosis for prolonged postoperative unconsciousness. This condition can be diagnosed only by electroencephalogram (EEG), and the institution of early treatment is associated with better prognosis. This case is presented to illustrate the occurrence of this rare clinical entity in a patient who had undergone extradural surgery.. An elderly female with no history of seizures or predisposing factors for convulsions underwent an uncomplicated left frontotemporal craniotomy for excision of an extradural meningioma. She was unresponsive following surgery, which could not be explained by the imaging and laboratory investigations. A subsequent EEG demonstrated periodic epileptiform discharges in lateralized left hemispheric distribution characteristic of seizures. The seizures were not effectively prevented by prophylactic fosphenytoin; however, the patient responded slowly to intravenous levetiracetam, which is known to be a more effective treatment for NCSE. The patient had no predisposing factors for the development of seizures and was undergoing an extradural surgery.. This case illustrates NCSE and emphasizes the importance of obtaining an electro-encephalogram early following craniotomy to diagnose any changes in the patient's mental status. This case also emphasizes that institution of early treatment is important to assure better prognosis.

Topics: Aged, 80 and over; Anticonvulsants; Craniotomy; Electroencephalography; Female; Humans; Levetiracetam; Meningeal Neoplasms; Meningioma; Piracetam; Postoperative Complications; Recovery Room; Status Epilepticus

Antiepileptic drugs are routinely given after craniotomy. Though phenytoin (PHT) is still the most commonly used agent, levetiracetam (LEV) is increasingly administered for this purpose. This retrospective study compared the use of LEV and PHT as monotherapy prophylaxis following supratentorial neurosurgery.. Patients receiving LEV monotherapy after supratentorial craniotomy were reviewed and compared to a control group of patients receiving PHT monotherapy.. One of 105 patients taking LEV and 9/210 patients taking PHT had seizures within 7 days of surgery (p = 0.17). Adverse drug reactions requiring change in therapy during hospitalization occurred in 1/105 patients taking LEV and 38/210 patients taking PHT (p < 0.001). Among patients followed for at least 12 months, 11/42 (26%) treated with LEV vs 42/117 (36%) treated with PHT developed epilepsy (p = 0.34); 64% remained on LEV, while 26% remained on PHT (p = 0.03).. Both levetiracetam (LEV) and phenytoin (PHT) were associated with a low risk of early postoperative seizures and a moderate risk of later epilepsy. LEV was associated with significantly fewer early adverse reactions than PHT and with a higher retention rate in patients who were followed for at least 1 year and developed epilepsy.

Topics: Adult; Aged; Aged, 80 and over; Anticonvulsants; Brain; Brain Injuries; Drug Tolerance; Drug-Related Side Effects and Adverse Reactions; Epilepsy; Female; Follow-Up Studies; Humans; Levetiracetam; Male; Middle Aged; Neurosurgical Procedures; Phenytoin; Piracetam; Postoperative Complications; Retrospective Studies; Supratentorial Neoplasms; Treatment Outcome

We conducted a retrospective study to evaluate the efficacy of levetiracetam as adjunctive therapy in patients with localization-related epilepsy, and specifically in the subset of patients for whom epilepsy surgery failed.. Eighty-two patients with uncontrolled partial-onset seizures treated with levetiracetam were identified; epilepsy surgery had failed for 21 (25.6%; group I), and 61 (74.4%) had no prior surgery (group II). Group I and group II patients were comparable in age (mean, 40.7 vs. 41.5 years) and age at seizure onset (mean, 14.4 vs. 18.2 years). Patients who had >/=50% reduction in seizure frequency were considered responders; the remaining patients were considered nonresponders.. In patients (group I) for whom surgery had failed, responder rate was 76.1% (16 of 21), including 10 (47.6%) patients who became seizure free. In nonsurgical patients (group II), responder rate was 34.3% (21 of 61), including nine (14.7%) patients who became seizure free. In group I, 11 (91.6%) of 12 temporal resection patients were responders, of whom eight were seizure free; of the remaining nine operated (extratemporal) patients, five (55.5%) were responders, and two were seizure free. In three responders, all in group I, a severe, delayed psychotic syndrome developed 4 to 9 months after levetiracetam introduction, leading to its discontinuation.. These findings suggest that adjunctive levetiracetam therapy should be considered early after failed epilepsy surgery, especially after temporal resection, and may have implications for its use before surgical intervention. Patients should be under close psychiatric observation in this clinical setting.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticonvulsants; Combined Modality Therapy; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Therapy, Combination; Electroencephalography; Epilepsies, Partial; Female; Humans; Levetiracetam; Male; Middle Aged; Piracetam; Postoperative Complications; Retrospective Studies; Treatment Failure; Treatment Outcome

Selecting an appropriate anticonvulsant for treatment of recipients of orthostatic liver transplants who have new-onset epileptic seizures can be challenging because first-line agents may contribute to worsening encephalopathy, alter the plasma concentration of immunosuppressive agents, and result in hepatotoxicity. We describe the case of a 55-year-old man who underwent orthotopic liver transplantation because of end-stage liver disease due to alcoholic cirrhosis and hepatitis C. He required two repeat transplantation procedures. After the last procedure, epileptic seizures developed, which were initially managed with phenytoin. However, the patient remained stuporous and mental status fluctuated. Breakthrough seizures later developed in the setting of rejection. Levetiracetam (500 mg orally, twice a day) was chosen for its favorable pharmacokinetic properties as an alternative to phenytoin. By the third day of levetiracetam therapy, the patient became more responsive. At most recent follow-up, 3 months after the start of levetiracetam therapy, the patient was still treated with levetiracetam monotherapy, and seizure control was judged to be excellent.

Topics: Anticonvulsants; Hepatitis C; Humans; Levetiracetam; Liver Cirrhosis, Alcoholic; Liver Transplantation; Male; Middle Aged; Piracetam; Postoperative Complications; Treatment Outcome