Prophylactic levetiracetam perioperatively in neurosurgery

Objective: To evaluate the prophylactic anticonvulsant use of levetiracetam in craniotomy-patients with contraindications for phenytoin. The prophylactic use of anticonvulsants in Neurosurgery is controversial because the evidence is inconsistent. Phenytoin is the only approved agent for this indication, but it can cause critical drops in blood pressure and heart rate. Therefore the routine prophylactic use of phenytoin for craniotomies needs careful consideration especially in cardiologically compromised patients. Hence, newer antiepileptic drugs (AEDs) with fewer adverse reactions have been recommended for this indication.

Methods: In a three months interval, 21 consecutive patients (mean age 57.6 years) with various non-traumatic intracranial pathologies received levetiracetam perioperatively and were included in this retrospective analysis. All 21 patients exhibited contraindications against phenytoin. Awake-craniotomy was performed in one patient with a glioblastoma in an eloquent area. All other craniotomies were performed under general anesthesia and all patients were transferred to the neurosurgical intensive care unit (ICU) for routine postoperative monitoring for 24 hours. Levetiractem was administered following a standardized operating procedure over a 5-day period. Patient data were collected and analyzed retrospectively. We determined the occurrence of seizures intra- and postoperatively within a seven days interval after the neurosurgical intervention.

Results: In this population no patient had side effects, adverse events or drug interactions that could be attributed to levetiracetam. None of the 21 patients experienced a seizure.

Conclusions: The prophylactic use of AEDs for craniotomies in patients without epilepsy is common clinical practice in many centers. However, the use of phenytoin in therapeutic doses is frequently accompanied by cardiovascular side effects. Therefore in the authors' institution a standardised regimen for the alternative use of levetiracetam was established when clinically seizure-prophylaxis was felt to be important. An earlier study reported a natural risk for post-craniotomy seizures of 16.7% in the placebo-treated control group and a 7.9% risk in the prophylactically phenytoin-treated verum group. Our results suggest that levetiracetam may be a safe and reasonable alternative to phenytoin for seizure prevention in Neurosurgery in patients with contraindications to phenytoin.