Do we need seizure prophylaxis for brain tumor surgery?

Commentary Seizures constitute very serious complications of brain tumor surgery as they often delay recovery and even cause death. Seizures occur in 20 to 40 percent of patients with brain tumors (1, 2). Frontal and parietal tumor location is more likely to be associated with seizures, as are slowly growing tumors (3). Craniotomies or biopsies, often done for diagnoses, may also increase risk of seizures. Previous retrospective studies reported no significant reduction of seizure incidence with pro-phylactic antiepileptic medications in patients with supraten-torial gliomas (4) and provided conflicting results on the role of seizure prophylaxis in patients with metastatic brain tumors (1). On the other hand, prospective studies have not specifically recruited patients with gliomas or metastatic supraten-torial tumors needing craniotomy to study the efficacy of antiepileptic drug (AED) prophylaxis in reducing postoperative seizures. Such studies either focused on brain tumor patients with or without craniotomy (2), or on craniotomy patients with or without brain tumors (5). Thus, the debate continues about seizure prophylaxis after craniotomy for intraparenchymal tumor resection. Wu et al. conducted a prospective randomized trial in patients with intraparenchymal brain tumors undergoing craniotomy to examine the use of phenytoin for postopera-tive seizure prevention (6). Eligible patients were ones with primary or metastatic supratentorial brain tumors who had not had seizures prior to surgery. They were randomized to a 7-day OBJECT: Seizures are a potentially devastating complication of resection of brain tumors. Consequently, many neuro-surgeons administer prophylactic antiepileptic drugs (AEDs) in the perioperative period. However, it is currently unclear whether perioperative AEDs should be routinely administered to patients with brain tumors who have never had a seizure. Therefore, the authors conducted a prospective, randomized trial examining the use of phenytoin for postop-erative seizure prophylaxis in patients undergoing resection for supratentorial brain metastases or gliomas. METHODS: Patients with brain tumors (metastases or gliomas) who did not have seizures and who were undergoing craniotomy for tumor resection were randomized to receive either phenytoin for 7 days after tumor resection (prophylaxis group) or no seizure prophylaxis (observation group). Phenytoin levels were monitored daily. Primary outcomes were seizures and adverse events. Using an estimated seizure incidence of 30% in the observation arm and 10% in the prophylaxis arm, a Type I error of 0.05 and a Type II error of 0.20, a target accrual of 142 patients (71 per arm) was planned. RESULTS: The trial was closed before completion of accrual because …