Comparative analysis of monotherapy versus duotherapy antiseizure drug management for postoperative seizure control in patients undergoing an awake craniotomy

Abstract

OBJECTIVE Postoperative seizures are a common complication in patients undergoing an awake craniotomy, given the cortical manipulation during tumor resection and the electrical cortical stimulation for brain mapping. However, little evidence exists about the efficacy of postoperative seizure prophylaxis. This study aims to determine the most appropriate antiseizure drug (ASD) management regimen following an awake craniotomy. METHODS The authors performed a retrospective analysis of data pertaining to patients who underwent an awake craniotomy for brain tumor from 2007 to 2015 performed by a single surgeon. Patients were divided into 2 groups, those who received a single ASD (the monotherapy group) and those who received 2 types of ASDs (the duotherapy group). Patient demographics, symptoms, tumor characteristics, hospitalization details, and seizure outcome were evaluated. Multivariable logistic regression was used to evaluate numerous clinical variables associated with postoperative seizures. RESULTS A total of 81 patients underwent an awake craniotomy for tumor resection of an eloquent brain lesion. Preoperative baseline characteristics were comparable between the 2 groups. The postoperative seizure rate was 21.7% in the monotherapy group and 5.7% in the duotherapy group (p = 0.044). Seizure outcome at 6 months' follow-up was assessed with the Engel classification scale. The duotherapy group had a significantly higher proportion of seizure-free (Engel Class I) patients than the monotherapy group (90% vs 60%, p = 0.027). The length of stay was similar, 4.02 days in the monotherapy group and 4.51 days in the duotherapy group (p = 0.193). The 90-day readmission rate was higher for the monotherapy group (26.1% vs 8.5% in the duotherapy group, p = 0.044). Multivariate logistic regression showed that preoperative seizure history was a significant predictor for postoperative seizures following an awake craniotomy (OR 2.08, 95% CI 0.56-0.90, p < 0.001). CONCLUSIONS Patients with a preoperative seizure history may be at a higher risk for postoperative seizures following an awake craniotomy and may benefit from better postoperative seizure control with postoperative ASD duotherapy.

Efficacy of antiepileptic drugs in glioma patients with epilepsy: a systematic review

“…In total, 3 studies documented efficacy of polytherapy including PHT. 47 , 65 , 66 The 6-month seizure freedom rate was 90% as reported in 1/3 studies. 47 …”

“…In total, 25 studies documented efficacy of LEV monotherapy. 18 , 25–39 , 47–49 , 51 , 53–57 The 6-month seizure freedom rate was presented in 9/25 studies and varied between 39% and 96% (WA = 60%), 25 , 26 , 30 , 32 , 34 , 37 , 47 , 54 , 55 while the 12-month seizure freedom rate was presented in 4/25 studies, ranging between 68% and 96% (WA = 74%). 31 , 35 , 53 , 54 A seizure reduction rate ≥50% at 6 months was presented in 2/25 studies and varied between 71% and 100% (WA = 82%).…”

“…We found 1 prospective and 11 retrospective observational studies reporting on PHT ( Table 2 ). 4 , 8 , 27 , 36 , 47 , 60–66 …”

Intraoperative Seizures in Awake Craniotomy for Perirolandic Glioma Resections That Undergo Cortical Mapping

“…We suspect that this perioperative course of prophylactic antiepileptics helped prevent intra/postoperative seizures in some patients, although the literature still varies on the efficacy of postoperative antiepileptic drugs. 32 Skardelly et al 33 associated increased preoperative peritumoral edema for gliomas with an increased likelihood of perioperative seizures. To see whether this applied to IOSs, we used our volumetric calculation program to evaluate preoperative edema for the perirolandic gliomas and found that the extent of peritumoral edema did not serve as a preoperative predictor.…”

Influence of supramarginal resection on survival outcomes after gross-total resection of IDH–wild-type glioblastoma

“…Our experience has been to perform more awake craniotomies with direct cortical and subcortical real-time mapping and neuropsychological testing at the time of surgery to maximize resection and minimize potential neurological deficit, and no significant difference in postoperative KPS has been observed between patients with ≤ 0% SMR and those with > 0% SMR. 6,12,[38][39][40][41][42][43][44] Additionally, no significant differences in percentages of SMR were noted between patients with deep-seated versus cortical tumor, or between those with tumors in eloquent versus noneloquent areas.…”