Prophylactic antiepileptic treatment with levetiracetam for patients undergoing supratentorial brain tumor surgery: a two-center matched cohort study

Efficacy and safety of levetiracetam in preventing postoperative seizures in adult patients with brain tumors: a meta-analysis

Objective

Seizures are one of the most common symptoms in patients with brain tumor. The efficacy of prophylactic antiepileptic agents in reducing postoperative seizures in patients with brain tumor remains disputed. We conducted this meta-analysis to evaluate the efficacy and safety of levetiracetam in preventing seizures in adult patients with brain tumor.

Review methods

We gathered studies comparing the effectiveness of levetiracetam with other antiepileptic drugs in preventing postoperative seizures in individuals with brain tumor from 2008 to 2023. We used the search terms levetiracetam, brain tumor, prevention, and seizures to retrieve relevant studies from the Pubmed, Medline, EMBASE, China National Knowledge Infrastructure, and Wanfang databases. The meta-analysis was conducted using RevMav 5.3 software.

Results

After the literature search and screening, nine English-language studies involving a total of 2,433 patients were analyzed. The meta-analysis revealed that levetiracetam had higher efficacy for preventing overall seizures than the control intervention (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.44-0.71, p < 0.00001). Subgroup analyses revealed that the efficacy of levetiracetam was superior to that of sodium valproate (OR 0.53, 95% CI 0.39-0.72, p < 0.0001) and phenytoin sodium (OR 0.35, 95% CI 0.19-0.62, p = 0.0004). No statistically significant difference in the efficacy of early seizure prophylaxis (OR 0.55, 95% CI 0.15-2.04, p = 0.37) was observed. The subgroup analysis revealed that the efficacy of levetiracetam for preventing early seizures was better than that of phenytion sodium (OR 0.13, 95% CI 0.03-0.56, p = 0.006). No statistically significant difference was noted in the preventive efficacy against late seizures (OR 0.75, 95% CI 0.27-2.03, p = 0.57). The incidence of adverse drug reactions was lower in the levetiracetam group than in the control group (OR 0.18, 95% CI 0.05-0.64, p = 0.008). Further subgroup analyses revealed that the incidence of adverse drug reactions in the levetiracetam group was lower than that in the phenytion sodium group (OR 0.06, 95% CI 0.02-0.21, p < 0.001).

Conclusion

Prophylactic levetiracetam decreases the frequency of postoperative seizures, particularly early postoperative seizures, in individuals with brain tumor, with superior effectiveness to phenytion sodium and sodium valproate. In addition, levetiracetam induced only minor adverse effects, with a lower occurrence rate of adverse reactions than phenytion sodium and valproate. Nevertheless, a potential for bias exists. Due to the limited number of high-quality randomized controlled trials included in this meta-analysis, prospective, multicenter, ethnically diverse, high-quality studies on levetiracetam are essential to determine the efficacy of preventive levetiracetam in managing postoperative seizures.

Systematic review registration

https://inplasy.com/inplasy-2023-6-0091/.

Chinese guideline on the application of anti-seizure medications in the perioperative period of supratentorial craniocerebral surgery

Seizures are a common symptom of craniocerebral diseases, and epilepsy is one of the comorbidities of craniocerebral diseases. However, how to rationally use anti-seizure medications (ASMs) in the perioperative period of craniocerebral surgery to control or avoid seizures and reduce their associated harm is a problem. The China Association Against Epilepsy (CAAE) united with the Trauma Group of the Chinese Neurosurgery Society, Glioma Professional Committee of the Chinese Anti-Cancer Association, Neuro-Oncology Branch of the Chinese Neuroscience Society, and Neurotraumatic Group of Chinese Trauma Society, and selected experts for consultancy regarding outcomes from evidence-based medicine in domestic and foreign literature. These experts referred to the existing research evidence, drug characteristics, Chinese FDA-approved indications, and expert experience, and finished the current guideline on the application of ASMs during the perioperative period of craniocerebral surgery, aiming to guide relevant clinical practice. This guideline consists of six sections: application scope of guideline, concepts of craniocerebral surgery-related seizures and epilepsy, postoperative application of ASMs in patients without seizures before surgery, application of ASMs in patients with seizures associated with lesions before surgery, emergency treatment of postoperative seizures, and 16 recommendations.

The use of prophylactic antiepileptic medication and driving restrictions for craniotomies among Australian and New Zealand neurosurgeons

Prophylactic antiepileptic drug (pAED) use for craniotomy surgery is currently not supported in literature [1-5] except possibly in traumatic brain injury (TBI) [6]. Post craniotomy driving restrictions using the Austroad guidelines are based upon literature on TBI and not specifically craniotomy [16-18]. This study was to review Australian and New Zealand neurosurgeons on their use of pAED and advice on driving restrictions post craniotomy surgery. A voluntary and anonymous survey link was distributed to the members of the Neurosurgical Society of Australasia (NSA) through the NSA newsletter. The survey was available on the SurveyMonkey platform in the year 2021 August to December. Questions regarding the use of pAED and duration of driving restrictions were presented to survey participants. Sixty-one (26 %) out of 231 neurosurgeons responded to the survey. Thirty-six percent of respondents stated that they prescribed pAEDs regularly whilst thirty-two percent of respondents did not routinely prescribe pAEDs for craniotomy surgery. Driving restrictions varied but the most common driving restriction post craniotomy surgery was 6 months. There were divided opinions among NSA members in regards to pAED use and driving restrictions. The rationale for pAED use and prolonged driving restrictions for craniotomy surgery needs to be re-evaluated with current literature. The significant effect this may have on the well-being and quality life of patients need to be considered before prescribing pAEDs or long driving restrictions.

Levetiracetam for Seizure Prophylaxis in Neurocritical Care: A Systematic Review and Meta-analysis

BACKGROUND

Levetiracetam is commonly used for seizure prophylaxis in patients with intracerebral hemorrhage (ICH), traumatic brain injury (TBI), supratentorial neurosurgery, and spontaneous subarachnoid hemorrhage (SAH). However, its efficacy, optimal dosing, and the adverse events associated with levetiracetam prophylaxis remain unclear.

METHODS

A systematic search of PubMed, Embase, and Cochrane central register of controlled trials (CENTRAL) database was conducted from January 1, 2000, to October 30, 2020, including articles addressing treatment with levetiracetam for seizure prophylaxis after SAH, ICH, TBI, and supratentorial neurosurgery. Non-English, pediatric (aged < 18 years), preclinical, reviews, case reports, and articles that included patients with a preexisting seizure condition or epilepsy were excluded. The coprimary meta-analyses examined first seizure events in (1) levetiracetam versus no antiseizure medication and (2) levetiracetam versus other antiseizure medications in all ICH, TBI, SAH, and supratentorial neurosurgery populations. Secondary meta-analyses evaluated the same comparator groups in individual disease populations. Risk of bias in non-randomised studies - of interventions (ROBINS-I) and risk-of-bias tool for randomized trials (RoB-2) tools were used to assess risk of bias.

RESULTS

A total of 30 studies (n = 6 randomized trials, n = 9 prospective studies, and n = 15 retrospective studies), including 7609 patients (n = 4737 with TBI, n = 701 with SAH, n = 261 with ICH, and n = 1910 with neurosurgical diseases) were included in analyses. Twenty-seven of 30 (90%) studies demonstrated moderate to severe risk of bias, and 11 of 30 (37%) studies used low-dosage levetiracetam (250-500 mg twice daily). In the primary meta-analyses, there were no differences in seizure events for levetiracetam prophylaxis (n = 906) versus no antiseizure medication (n = 2728; odds ratio [OR] 0.79, 95% confidence interval [CI] 0.53-1.16, P = 0.23, fixed-effect, I² = 26%, P = 0.23 for heterogeneity) or levetiracetam (n = 1950) versus other antiseizure prophylaxis (n = 2289; OR 0.84, 95% CI 0.55-1.28, P = 0.41, random-effects, I² = 49%, P = 0.005 for heterogeneity). Only patients with supratentorial neurosurgical diseases benefited from levetiracetam compared with other antiseizure medications (median 0.70 seizure events per-patient-year with levetiracetam versus 2.20 seizure events per-patient-year for other antiseizure medications, OR 0.34, 95% CI 0.20-0.58, P < 0.001, fixed-effects, I² = 39%, P = 0.13 for heterogeneity). There were no significant differences in meta-analyses of patients with ICH, SAH, or TBI. Adverse events of any severity were reported in a median of 8% of patients given levetiracetam compared with 21% of patients in comparator groups.

CONCLUSIONS

Based on the current moderately to seriously biased heterogeneous data, which frequently used low and possibly subtherapeutic doses of levetiracetam, our meta-analyses did not demonstrate significant reductions in seizure incidence and neither supports nor refutes the use of levetiracetam prophylaxis in TBI, SAH, or ICH. Levetiracetam may be preferred post supratentorial neurosurgery. More high-quality randomized trials of prophylactic levetiracetam are warranted.

Levetiracetam-induced interstitial lung disease in a patient with advanced lung cancer

An 85-year-old woman with antibiotics-resistant pneumonia after surgery for metastatic brain tumor from lung cancer was consulted to our department. Chest CT showed diffuse GGO bilaterally. BALF showed elevated ratios of lymphocytes and CD4/CD8. Tests for bacteria, mycobacteria, and fungi were negative. She improved following levetiracetam discontinuance and systemic corticosteroid administration, and we diagnosed levetiracetam-induced lung injury. Although levetiracetam is widely used, few reports of levetiracetam-induced pneumonia exist. Changes in chest images may occur after levetiracetam administration if patients have multiple risk factors for development of drug-induced interstitial lung disease. Bronchoscopy is useful for differential diagnosis if new lung lesions appear after starting levetiracetam.

Antiepileptic Drugs in the Management of Cerebral Metastases

Seizures represent a common and debilitating complication of central nervous system metastases. The use of prophylactic antiepileptic drugs (AEDs) in the preoperative period remains controversial, but the preponderance of evidence suggests that it is not helpful in preventing seizure and instead poses a significant risk of adverse events. Studies of postoperative seizure prophylaxis have not shown substantial benefit, but this practice remains widespread. Careful analysis of the risk of seizure based on patient-specific factors, such as tumor location and primary tumor histology, should guide the physician's decision on the initiation and cessation of prophylactic AED therapy.