Postoperative Anticonvulsant Prophylaxis for Patients Treated for Cerebral Aneurysms

Abstract

The incidences of postoperative seizures and side effects were evaluated in 193 patients with cerebral aneurysm who received anticonvulsant prophylaxis and underwent 224 craniotomies for cerebral aneurysms between 1993 and 1995. The patients were 73 males and 120 females aged between 31 and 80 years. One hundred and sixteen patients had ruptured cerebral aneurysms and 108 had unruptured aneurysms. Phenytoin followed by valproic acid were administered. Early postoperative seizures occurred in five patients (4 with ruptured and 1 with unruptured aneurysms) within 14 days after surgery. Late postoperative seizures occurred in four different patients with ruptured aneurysms more than 14 days after surgery. The presence of cortical lesions detected by cerebral computed tomography and occurrence of symptomatic vasospasm were correlated with the occurrence of early postoperative seizure (p < 0.05). Three of the four patients with late postoperative seizure had cortical lesions and two were receiving continued medication. Side effects that warranted discontinuation of therapy were seen in the follow-up period in 12.9% of patients. Anticonvulsant prophylaxis is not recommended due to the higher incidence of side effects than seizure, except in patients in poor clinical condition for the purpose of brain protection. Otherwise, anticonvulsant medication should be initiated at the time of the initial seizure attack.

Add‐on Phenytoin Fails to Prevent Early Seizures after Surgery for Supratentorial Brain Tumors: A Randomized Controlled Study

“…Whatever the mechanisms underlying these findings, our results provide strong support for the view that shortterm PHT prophylaxis has no useful role in the routine management of patients undergoing craniotomy for supratentorial tumors (2,19,20), particularly when other AEDs have been already prescribed. Whether prophylaxis could be indicated in specific subgroups of patients at high risk for seizures can be addressed only in a large multicenter study.…”

“…Many authors advise against prophylactic drug treatment (2,6,19,20), others suggest that PHT may be indicated for the immediate postoperative period (7,18,21,22). More remarkably, the practice of prescribing long-term AED prophylaxis remains widespread, either in all patients at large or in specific patient subgroups (23,24), despite lack of adequate evidence that postoperative and posttraumatic epilepsy can be prevented by treatment (4,6,9,14,25).…”

The efficacy of antiepileptic drug prophylaxis in the prevention of early and late seizures following repair of intracranial aneurysms

“…There were 281 treated aneurysms (mean aneurysms/patient 1.08, range, 1-4). The mean maximum aneurysm diameter was 7.04 mm (range, [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. A total of 234 aneurysms (83%) were located in the anterior circulation and 47 (17%) in the posterior circulation.…”

“…5,6 However the etiology of these seizures, and the relative contribution of surgical factors, as well as intrinsic pathophysiological factors associated with aneurysm rupture, remains poorly characterised. Seizures represent a serious adverse outcome following intracranial procedures, and have been associated with increased mortality even when in remission.…”

“…3 In reviewing these and other more recent experiences, the Stroke Council of America guidelines, published in 2009, recommend against routine perioperative AED use in ruptured aneurysms due to a paucity of evidence of benefit. 4 The risk of epilepsy following intervention for unruptured aneurysms appears to be significantly lower, 5,6 and no specific recommendation has been made regarding their routine use for elective aneurysm repair. 4 Despite their efficacy in treatment of patients with established epilepsy, anticonvulsant medications have not been proven to prevent the onset of seizure in previously asymptomatic individuals.…”