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  • Prophylactic anticonvulsant therapy prior to neurosurgery is controversial
  • Patients should continue their preoperative anticonvulsants as long as they have therapeutic drug levels
  • Phenytoin 100 mg Q8 hours or levetiracetam 500 mg are the most common regimens
  • Levetiracetam is now being used more often due to broad-spectrum seizure coverage and lower side effects, and serum therapeutic levels do not need to be checked

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Common Preoperative Anticonvulsant Regimens and Side Effects
DrugDoseSide effects
Carbamazepine (Tegretol®)400 mg po tidBlurred vision, ataxia, sedation, hyponatremia, rash
Ethosuximide (Zarontin®)500 mg po q dayNausea, vomiting, ataxia, GI distress, drowsiness
Gabapentin (Neurontin®)300–1200 mg po tidDrowsiness, weight gain, peripheral edema
Lamotrigine (Lamictal®)200 mg po bidRash, Stevens–Johnson’s, red cell aplasia, DIC, hepatic or renal failure
Levetiracetam (Keppra®)1000 mg po bidIrritability, somnolence
Oxcarbazepine (Trileptal®)600 mg po bidHyponatremia, rash, interactions with oral contraceptives
Phenobarbital (Solfoton®)100 mg po q dayDrowsiness, confusion, slurred speech, ataxia, hypotension, respiratory depression, nystagmus
Phenytoin (Dilantin®)300–400 mg po q dayVertigo, somnolence, ataxia, gingival hyperplasia, hirsutism
Topiramate (Topamax®)150–200 mg po bidCNS side effects, nephrolithiasis, open-angle glaucoma, weight loss
Valproate (Depakene®)250–500 mg po tidGI disturbance, sedation, weight gain, somnolence, hair loss, thrombocytopenia
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Anesthetic Choice

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  • Inhalational anesthetics are primarily antiepileptic
  • Nitrous oxide tends to inhibit seizure spikes
  • Benzodiazepines and propofol are antiepileptic
  • Ketamine, etomidate, and methohexital can be proconvulsant with low dosages and should be avoided
  • High doses of fentanyl and alfentanil can trigger epileptiform spike activity on EEG
  • Large doses of meperidine, atracurium, or cisatracurium should be avoided due to epileptogenic metabolites normeperidine and laudanosine
  • Regional anesthesia is encouraged as long as optimal surgical environment is maintained

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If seizure occurs

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  • Treat with small dose of thiopental 2 mg/kg, midazolam 2–5 mg, or propofol 1–2 mg/kg
  • Consider phenytoin 500–1000 mg IV slow loading dose (or the equivalent as fosphenytoin: less likely to cause hypotension) for prevention of recurrent seizures
  • If seizures refractory to above, administer general anesthetic doses of inhalational or IV anesthetics

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  • Drug levels of older antiepileptics such as phenytoin need to be monitored
  • If patient cannot take po postoperatively, convert to IV and adjust dose

1. Bhagat H. Anaesthesiologist’s role in management of an epileptic patient. Indian J Anaesth. 2006;50(1):20–22.
2. Kofke W, Tempelhoff R, Dasheiff R. Anesthetic implications of epilepsy, status epilepticus, andepilepsy surgery. J Neurosurg Anesthesiol. 1997 Oct;9(4):349–372.   [PubMed: 9339409]
3. Kofke W. Anesthetic management of the patient with epilepsy or prior seizures. Curr Opin Anaesthesiol. 2010 Jun;23:391–399.   [PubMed: 20421790]
4. Komotar R. Prophylactic antiepileptic drug therapy in patients undergoing supratentorial meningioma resection: a systematic analysis of efficacy. J Neurosurg. 2011 Sep;115(3):483–490.   ...

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