Neuroscience in Anesthesiology and Perioperative Medicine

Section Editor: Gregory J. Crosby

Perioperative Seizures in Patients with a History of a

Seizure Disorder
Adam D. Niesen, MD, Adam K. Jacob, MD, Lucyna E. Aho, RN, Emily J. Botten, RN,
Karen E. Nase, RN, Julia M. Nelson, RN, and Sandra L. Kopp, MD

BACKGROUND: The occurrence of perioperative seizures in patients with a preexisting seizure

disorder is unclear. There are several factors unique to the perioperative period that may
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increase a patient’s risk of perioperative seizures, including medications administered, timing of

medication administration, missed doses of antiepileptic medications, and sleep deprivation.
We designed this retrospective chart review to evaluate the frequency of perioperative seizures
in patients with a preexisting seizure disorder.
METHODS: We retrospectively reviewed the medical records of all patients with a documented
history of a seizure disorder who received an anesthetic between January 1, 2002 and December
31, 2007. Patients excluded from this study include those who had an outpatient procedure or
intracranial procedure, ASA classification of V, pregnant women, and patients younger than 2
years of age. The first hospital admission of at least 24 hours during which an anesthetic was
provided was identified for each patient. Patient demographics, character of the seizure disorder,
details of the surgical procedure, and clinically apparent seizure activity in the perioperative
period (within 3 days after the anesthetic) were recorded.
RESULTS: During the 6-year study period, 641 patients with a documented seizure disorder were
admitted for at least 24 hours after an anesthetic. Twenty-two patients experienced perioperative
seizure activity for an overall frequency of 3.4% (95% confidence interval, 2.2%–5.2%). The
frequency of preoperative seizures (P ⬍ 0.001) and the timing of the most recent seizure (P ⬍
0.001) were both found to be significantly related to the likelihood of experiencing a perioperative
seizure. As the number of antiepileptic medications increased, so did the frequency of
perioperative seizures (P ⬍ 0.001). Neither the type of surgery nor the type of anesthetic (general
anesthesia, regional anesthesia, or monitored anesthesia care) affected the frequency of
perioperative seizures in this patient population.
CONCLUSIONS: We conclude that the majority of perioperative seizures in patients with a
preexisting seizure disorder are likely related to the patient’s underlying condition. The frequency
of seizures is not influenced by the type of anesthesia or procedure. Because patients with
frequent seizures at baseline are likely to experience a seizure in the perioperative period, it is
essential to be prepared to treat seizure activity regardless of the surgical procedure or
anesthetic technique. (Anesth Analg 2010;111:729 –35)

S eizures are a common occurrence in the general

population, with an 8% to 10% lifetime risk of a single
seizure and a 3% chance of a persistent seizure
disorder.1,2 Therefore, patients with a seizure disorder
make up a significant portion of individuals presenting for
anesthesia and surgery. Despite this, no studies have
reported the frequency of seizure activity during the peri-
operative period in patients with a seizure disorder. This
information could be used to better counsel these patients
regarding the likelihood of experiencing a seizure in the
From the Department of Anesthesiology, Mayo Clinic College of Medicine,
Rochester, Minnesota.
Accepted for publication March 29, 2010.
ADN is currently at Austin Medical Center, Mayo Health System, Austin,
MN.
Supported by the Department of Anesthesiology, Mayo Clinic College of
Medicine, Rochester, MN.
Disclosure: The authors report no conflicts of interest.
Address correspondence and reprint requests to Sandra L. Kopp, MD,
Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First
St. SW, Rochester, MN 55905. Address e-mail to kopp.sandra@mayo.edu.
Copyright © 2010 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e3181e534a4
perioperative period, including possible factors that could
affect this risk.
There are several factors that alter the risk of having a
seizure, including but not limited to antiepileptic medication
noncompliance, timing of antiepileptic medication adminis-
tration, altered gastrointestinal absorption of antiseizure
medications, electrolyte disturbances, and sleep depriva-
tion.3– 6 These are common conditions during the periopera-
tive period. In addition, a number of medications routinely
used in the perioperative period can affect the seizure thresh-
old or have significant interactions with antiepileptic drugs.7
A recent review of patients with a seizure disorder who
underwent a regional anesthetic technique estimated the
frequency of perioperative seizures at 5.8% and concluded
that the majority of postoperative seizures were related to the
patient’s underlying condition and that local anesthetic ad-
ministration in this population is not contraindicated.8 How-
ever, there are no data estimating the overall perioperative
seizure risk in patients with a known seizure disorder under-
going all types of anesthesia. This retrospective chart review
was designed to evaluate the incidence of perioperative
seizures in patients undergoing any type of anesthesia for

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Perianesthetic Seizures in Patients with a Seizure Disorder
nonneurologic procedures. The results of this chart review
will allow a more accurate estimate of the risk for periopera-
tive seizure in patients with a history of seizure disorder.
Additionally, this study may identify factors that affect the
likelihood of perioperative seizures in these patients.
METHODS
After IRB approval, we conducted a retrospective query of
the Mayo Clinic Life Science System database from January
1, 2002 through December 31, 2007 to identify all patients
who met the following inclusion criteria: age ⱖ2 years,
hospital admission ⬎24 hours’ duration, received any
anesthetic (general anesthesia, regional anesthesia, or
monitored anesthesia care) during their hospital admission,
and seizure disorder documented in the medical record
before hospital admission. Patients with a seizure disorder
were identified by searching for ICD-9 codes 345.0 to 345.91
and 780.3 to 780.39. From the 115,120 patients identified,
the database was limited to those patients with one or more
routine hospital admissions during the study period with a
length of stay ⬎2 days with an anesthetic administered
during the hospitalization. A manual chart review was
performed for these 1778 patients.
Patients were excluded if they had 1 of the following
conditions: no confirmed seizure disorder (e.g., single
febrile seizure in childhood, acute symptomatic seizure
attributed to trauma, electrolyte disturbance, infection, or
alcohol withdrawal), had anesthesia for an outpatient or
intracranial procedure, were younger than 2 years of age,
ASA V classification, or pregnant women who received a
labor epidural as their sole anesthetic. For the 641 patients
meeting inclusion criteria, the first hospital admission
during which an anesthetic was provided for a nonneurol-
gic surgical procedure was manually reviewed for each
patient. We defined the perioperative period as the time
from the start of the surgical procedure until the third
hospital day or hospital dismissal, whichever time period
was shorter. Patient demographics including age, gender,
ASA physical status, and urgency (elective or emergent) of
the surgery were recorded. We recorded the characteristics
and clinical course of the seizure disorder, including type of
seizure disorder (simple partial, complex partial, general-
ized nonconvulsive, or generalized convulsive), seizure
frequency, most recent seizure before surgery, previous
surgical management for the seizure disorder, antiepileptic
medications, other medications the patient was taking at
the time of surgery, and blood levels of antiepileptic drugs
within 2 weeks of the surgical procedure. If the patient had
multiple seizure types at baseline, the most frequently
occurring seizure type was recorded.
Details of the surgical procedure and the anesthetic were
also documented, including type of surgical procedure,
duration of inpatient stay (days), type of anesthetic (re-
gional, general, monitored anesthesia care), primary induc-
tion drug, type of anesthetic maintenance, type of regional
block, and use of any benzodiazepine during the anesthetic.
For all patients identified as experiencing a clinically ap-
parent seizure documented in the daily nursing and
progress notes within 3 days after surgery, the circum-
stances surrounding the event were documented, including
the time of seizure, type of seizure, recent local anesthetic
730 www.anesthesia-analgesia.org
administration, antiepileptic medications, medications ad-
ministered at the time of the seizure, and recent antiepileptic
drug blood levels. Information pertaining to the seizure
activity was derived from anesthetic records, postanesthesia
care unit notes, and daily progress notes of the primary
service, medical consultation team(s), and the anesthesia pain
service. The cause of the seizure was determined based on the
frequency of preoperative seizures, antiepileptic drug levels,
electroencephalographic results, radiographic imaging ob-
tained, results from neurology consultation, and documenta-
tion detailing seizure activity.
Baseline patient and procedural characteristics were
summarized using mean ⫾ SD for continuous variables
and frequency percentages for categorical variables. The
frequency of postoperative seizures was summarized using
a point estimate and exact 95% confidence interval. Base-
line characteristics were compared between those who did
and did not experience seizures using the rank sum test for
continuous variables and the Fisher exact test for categori-
cal variables. In all cases, a 2-tailed P value ⬍0.05 was
considered statistically significant.
RESULTS
During the 6-year study period, 641 patients older than 2
years with a documented seizure disorder were admitted
for at least 24 hours and had anesthesia for a nonneurologic
surgical procedure. The mean age ⫾ SD of patients was
52.8 ⫾ 22.7 years. Other patient and procedural character-
istics at the time of anesthesia and surgery are provided in
Table 1. For these patients, the median (25th, 75th percen-
tile) length of hospital stay was 4 (2, 7) days. There were 22
patients (3.4%; 95% confidence interval, 2.2%–5.2%) who
experienced a seizure during the defined perioperative
period. Using univariate analysis, patients with clinically
apparent seizure activity postoperatively were found to be
significantly younger than those who did not experience a
seizure (40.3 ⫾ 22.2 vs 53.3 ⫾ 22.6 years; P ⫽ 0.011).
Preoperative use of multiple antiepileptic medications (P ⬍
0.001), shorter length of time between last seizure episode
and hospital admission (P ⬍ 0.001), and more frequent
seizures at baseline (P ⬍ 0.001) were all found to be
associated with an increased risk for perioperative seizure
(Table 2).
Of the 22 patients who experienced perioperative seizure
activity, 19 patients had a seizure that was consistent with
their usual seizure type. There was no association between
anesthetic technique, induction drug, or type of maintenance
and perioperative seizure occurrence. In addition, no relation-
ship was found regarding surgical procedure type and peri-
operative seizure occurrence. Six patients had a documented
subtherapeutic antiepileptic drug level. An additional 2 pa-
tients did not receive their antiepileptic medications per their
usual schedule, 1 because of vomiting and 1 because of
intestinal surgery. Antiepileptic drug levels were not assessed
in these 2 patients (Table 3).
Two patients received regional anesthesia, but their
seizures were not related to the regional block. One of these
patients received a single-injection fascia iliaca block for
postoperative pain control for a muscle biopsy. She expe-
rienced hundreds of complex partial seizures daily at
ANESTHESIA & ANALGESIA
Table 1. Patient and Procedural Characteristics Table 2. Characteristics Significantly Associated
(n ⴝ 641) with Perioperative Seizure
Characteristic n % Characteristic n Seizure P valuea
Sex Age (y) 0.012
Male 321 50.1 ⱕ17 73 6 (8.2%)
Female 320 49.9 18–30 38 1 (2.6%)
ASA physical status 31–45 106 4 (3.8%)
I 17 2.7 46–60 151 6 (4%)
II 197 30.7 61–75 148 4 (2.7%)
III 388 60.5 75⫹ 125 1 (0.8%)
IV 39 6.1 No. of antiseizure medications ⬍0.001
Time since last seizure None 96 0 (0%)
0–7 d 46 7.2 1 380 5 (1.3%)
8–28 d 29 4.5 2 120 9 (7.5%)
29–180 d 45 7 ⱖ3 45 8 (17.8%)
181–365 d 36 5.6 Time from last seizure to surgery ⬍0.001
365⫹ d 417 65.1 0–7 d 46 8 (17.4%)
Not documented 68 10.6 8–28 d 29 6 (20.7%)
Seizure frequency 29–180 d 45 4 (8.9%)
ⱖ1/d 16 2.5 181–365 d 36 2 (5.6%)
ⱖ1/wk 22 3.4 365⫹ d 417 0 (0%)
ⱖ1/mo 32 5 Not documented 68 2 (2.9%)
ⱖ1/y 86 13.4 Frequency of seizures ⬍0.001
⬍1/y 429 66.9 1⫹ seizures/d 16 6 (37.5%)
Not documented 56 8.7 1⫹ seizures/wk 22 4 (18.2%)
Type of seizures 1⫹ seizures/mo 32 3 (9.4%)
Simple partial 56 8.7 1⫹ seizures/y 86 7 (8.1%)
Complex partial 224 34.9 ⬍1 seizure/y 429 1 (0.2%)
Generalized nonconvulsive 44 6.9 Not documented 56 1 (1.8%)
Generalized convulsive 299 46.6 a
Age was compared between those with and without postoperative seizure
Other 5 0.8 using the rank sum test. Other characteristics were compared between
Not documented 13 2 groups using the Fisher exact test.
No. of antiepileptic medicationsa
None 96 15
1 380 59.3 generalization at baseline, and had multiple generalized
2 120 18.7 tonic-clonic seizures 24 to 48 hours postoperatively. The
ⱖ3 45 7
Type of surgery neurology service thought these seizures were his typical
General/intraabdominal, transplant, plastic 145 22.6 seizures and were likely triggered by hyponatremia (so-
Urologic, gynecologic, obstetric 81 12.6 dium level of 125 mmol/L). This patient also had subthera-
Orthopedic 83 12.9 peutic levels of phenytoin and phenobarbital at the time of
Endocrine, ENT, ophthalmologic 199 31
the seizures.
Thoracic, cardiac, vascular 55 8.6
Radiology/cardiac/vascular lab, bronchoscopy 78 12.2 Three patients had seizures that were different from
Type of anesthesia their typical seizures. One patient had a complex partial
General 467 72.9 seizure after antiepileptic medications were withdrawn
Regional 47 7.3 because of Stevens-Johnson syndrome. This patient had a
General ⫹ regional 56 8.7
Monitored anesthesia care 71 11.1 tracheostomy for prolonged airway management and was
Type of regional block receiving a benzodiazepine infusion for sedation and sei-
None 532 83 zure control at the time of this complex partial seizure,
Central neuraxialb 58 9 which was thought to be an isolated incident. The patient
Peripheral 38 5.9
did have further seizures during hospitalization, but they
Central neuraxial and peripheral 13 2
Benzodiazepine given during anesthetic were generalized convulsive seizures, which were typical
No 243 37.9 for this patient. The other 2 patients who had seizures of a
Yes 398 62.1 different type than their usual seizures had a history of
ENT ⫽ ear-nose-throat; ASA ⫽ American Society of Anesthesiology. seizures in the recovery room after previous anesthetics.
a
There were 545 patients (85%) who were taking at least 1 antiepileptic Neither of these patients experienced frequent seizure
medication at the time of surgery. Of these, 380 (69.7%) were taking 1
medication, 120 (22%) were taking 2 medications, 42 (7.7%) were taking
activity at baseline, and a triggering cause could not be
3 medications, and 3 (0.6%) were taking 4 medications. Overall, there were found during the previous episodes for either patient. Both
144 medication levels assessed within 14 d before surgery. Of these, 34.8% of these patients also had clinically evident seizure activity
were below the therapeutic level, 56.8% were within the therapeutic level, and
17.4% were above the therapeutic level. in the recovery room during the current study period. The
b
Spinal, epidural, caudal, or combined spinal epidural. seizures were different than what was typical for each
patient. Similar to the previous episodes, a triggering cause
baseline, and encountered these same seizures in the recov- could not be identified.
ery room without any other signs or symptoms of local
anesthetic toxicity. The second patient received a thoracic DISCUSSION
epidural catheter for postoperative pain control. The pa- The definition of seizure is the clinical manifestation of
tient experienced complex partial seizures with secondary abnormally hyperexcitable cortical neurons. Many people

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Perianesthetic Seizures in Patients with a Seizure Disorder

Table 3. Patients Experiencing Perioperative Seizures

ASA
physical Last seizure Frequency of
Sex/age (y) status Surgery type Seizure typical for patient before surgery seizures
Male/8 III General/abdominal/intestinal Generalized convulsive 0–7 d 1⫹/d

Female/11 III General/abdominal/intestinal Generalized nonconvulsive 0–7 d 1⫹/d

and simple partial
Female/12 II General/abdominal/intestinal Complex partial 0–7 d 1⫹/d

Male/12 II Orthopedic Generalized convulsive 0–7 d 1⫹/d

Female/12 III Radiology/IR/vascular lab Complex partial 0–7 d 1⫹/d

Male/17 III Vascular Simple partial 29–180 d 1⫹/y

Female/18 II Radiology/IR/vascular lab Generalized convulsive 0–7 d 1⫹/d

Female/30 III ENT Generalized convulsive 8–28 d 1⫹/mo

Female/32 III General/abdominal/intestinal Generalized convulsive 8–28 d 1⫹/wk

Female/33 III Orthopedic Simple partial 8–28 d 1⫹/wk

Male/42 III Endocrine Generalized convulsive Not documented 1⫹/y

Male/44 IV General/abdominal/intestinal Generalized convulsive 181–365 d 1⫹/y

Female/51 III Radiology/IR/vascular lab Complex partial 0–7 d 1⫹/wk

Male/53 III Orthopedic Generalized convulsive 8–28 d 1⫹/wk

Female/53 III General/abdominal/intestinal Complex partial 29–180 d 1⫹/y

Female/53 III ENT Generalized convulsive 29–180 d ⬍1/y

Female/57 III Urology Complex partial 0–7 d 1⫹/mo

Male/61 III Cardiac Simple partial 8–28 d 1⫹/y

Female/63 III Orthopedic Generalized convulsive 181–365 d 1⫹/y

Male/64 II Thoracic Complex partial and 8–28 d 1⫹/y

generalized convulsive

Male/70 III Orthopedic Generalized nonconvulsive 29–180 d 1⫹/mo

Male/78 III Cardiac catheterization/ Generalized convulsive Not documented Not documented
echocardiography
PACU ⫽ postanesthesia care unit; IR ⫽ interventional radiology; ENT ⫽ ear-nose-throat; ASA ⫽ American Society of Anesthesiology.

732 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA

Table 3. (Continued)
Preoperative
antiepileptic Timing of
medications Anesthetic postoperative seizure Comments
Felbamate, levetiracetam General 12–24 h after surgery ⬎1 perioperative seizure; typical of patient’s
usual seizures; vomited medications
Clonazepam, topiramate General 12–24 h after surgery ⬎1 perioperative seizure; typical of patient’s
usual seizures
Lamotrigine, valproate General and regional 0–12 h after surgery Multiple seizures in PACU; typical of patient’s
(single-injection usual seizure
fascia iliaca)
Felbamate, levetiracetam General 12–24 h after surgery ⬎1 perioperative seizure; typical of patient’s
usual seizure; subtherapeutic antiepileptic
level
Carbamazepine, General 0–12 h after surgery ⬎1 perioperative seizure; typical of patient’s
lamotrigine, usual seizure
levetiracetam
Levetiracetam, General 12–24 h after surgery Typical of patient’s usual seizure
oxcarbazepine
Clonazepam, tiagabine, General 12–24 h after surgery ⬎1 perioperative seizure; typical of patient’s
topiramate, usual seizure
clonazepam
Topiramate General ⬎48 h after surgery Partial seizure, not typical of patient’s usual
seizure; patient withdrawn from
antiepileptics because of Stevens-Johnson
syndrome
Gabapentin, General 0–12 h after surgery Typical of patient’s usual seizure; unable to
phenobarbital, take oral medications at the time of seizure
valproate
Clonazepam, General 12–24 h after surgery ⬎1 perioperative seizure; typical of patient’s
carbamazepine, usual seizure; subtherapeutic antiepileptic
gabapentin, level
levetiracetam
Lamotrigine General 24–48 h after surgery ⬎1 perioperative seizure; typical of patient’s
usual seizure; subtherapeutic antiepileptic
level
Levetiracetam General ⬎48 h after surgery ⬎1 perioperative seizure; typical of patient’s
usual seizure; hypoxia possible contributing
cause
Phenobarbital, MAC/sedation 0–12 h after surgery Typical of patient’s usual seizure
topiramate
Carbamazepine, General 12–24 h after surgery Typical of patient’s usual seizure;
phenobarbital, subtherapeutic antiepileptic level
phenytoin
Phenobarbital MAC/sedation 0–12 h after surgery ⬎1 perioperative seizure, starting in PACU;
generalized seizure, not typical of patient’s
usual seizure; history of seizures after
anesthesia
Phenytoin General 12–24 h after surgery Typical of patient’s usual seizure;
subtherapeutic antiepileptic level
Clonazepam, topiramate, General 0–12 h after surgery Status epilepticus 2 h after anesthesia end;
zonisamide ⬎1 perioperative seizure; typical of
patient’s usual seizure
Lorazepam, phenytoin General 12–24 h after surgery Typical of patient’s usual seizure;
subtherapeutic antiepileptic level
Phenobarbital General 0–12 h after surgery ⬎1 perioperative seizure, starting in PACU;
partial seizure, not typical of patient’s usual
seizure; history of seizures after anesthesia
Phenobarbital, phenytoin, General and regional 24–48 h after surgery ⬎1 perioperative seizure; typical of patient’s
levetiracetam (epidural) usual seizure; electrolyte abnormality;
subtherapeutic antiepileptic level
Carbamazepine, General 24–48 h after surgery Typical of patient’s usual seizure;
phenobarbital, subtherapeutic antiepileptic level
phenytoin
Carbamazepine, MAC/sedation ⬎48 h after surgery Typical of patient’s usual seizure
levetiracetam

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Perianesthetic Seizures in Patients with a Seizure Disorder
experience an isolated seizure during their lifetime (e.g.,
febrile seizure in children, acute symptomatic seizures
caused by trauma, electrolyte disturbances, infection, and
alcohol withdrawal) but are not regarded as having a
seizure disorder. In Rochester, MN, the cumulative inci-
dence of epilepsy through age 74 years is 3.0%, with an
incidence of any seizure incident near 10%.9 Given this
large segment of the population with a seizure disorder, it
is not uncommon for these patients to present for surgery
and anesthesia.
Recent data suggest that the occurrence of postoperative
seizures in patients with a seizure disorder undergoing
regional anesthesia is infrequent, and that regional anes-
thesia in such patients is not contraindicated.8 A multi-
center prospective cohort study in Thailand reported an
incidence of postoperative seizure of 3.1 per 10,000 for all
patients undergoing all surgical (including neurosurgical
procedures) and anesthesia types, but the incidence of
postoperative seizure in patients with an underlying sei-
zure disorder was not reported.10 Recently, a much smaller
retrospective study examined the incidence of seizures in
patients with epilepsy undergoing general anesthesia.11
Seizures were observed in 2% of patients and they reported
no adverse effect after receiving general anesthesia.
There are many factors that can increase the likelihood
of seizure activity in patients with a seizure disorder,
including changes in antiepileptic drug levels, fatigue,
stress, sleep deprivation, menstruation, electrolyte distur-
bances, and excessive alcohol intake.3,6,12 Many situations
arise in the perioperative period that can affect antiepileptic
drug levels, including preoperative medication noncompli-
ance, changes in dosing schedule, perioperative medica-
tions, anesthetic exposure, and changes in gastrointestinal
motility leading to delayed absorption and reduced bio-
availability.3,5 In particular, when patients are advised to
take nothing by mouth preoperatively, they may omit their
scheduled doses of antiepileptic medications. This is exac-
erbated postoperatively in patients who are not allowed to
take oral medications because of their surgical procedure or
are unable to tolerate oral intake because of nausea and
vomiting. Decreased antiepileptic drug serum levels may
contribute to perioperative seizure activity.4
Nine patients in our study experienced perioperative
seizure activity that was likely influenced by fluctuations in
antiepileptic levels. Six of these patients had documented
subtherapeutic antiepileptic levels, 2 had interruptions in
their usual dosing schedule because of vomiting and
nothing-by-mouth status, and 1 had antiepileptic medica-
tions intentionally withdrawn because of Stevens-Johnson
syndrome. The therapeutic level for antiepileptic medica-
tions is a complex measurement that depends on the
individual patient and the timing of the blood draw, and it
frequently lies outside of the laboratory standard therapeu-
tic range. However, the neurologists consulting on these
cases thought that the levels obtained were below the
therapeutic range for these particular patients, which con-
tributed to their perioperative seizure activity. This under-
scores the importance of maintaining an inpatient dosing
regimen as close as possible to what the patient is accus-
tomed to as an outpatient. This can be challenging because
734 www.anesthesia-analgesia.org
a number of antiepileptics do not have a parenteral formu-
lation and the interpretation of blood levels may be difficult
for practitioners unfamiliar with these medications. Pa-
tients requiring multiple medications for seizure control
present a particular challenge, because these patients are at
a greater risk of seizure recurrence when medications are
withdrawn or their dosage is reduced.13 Consultation with
a neurologist may be necessary to formulate the most
effective plan for these patients in the perioperative period.
The patients who experienced seizure activity periop-
eratively were significantly younger than patients who did
not. In addition, the incidence of epilepsy is higher in the
intellectually and developmentally disabled population,
and there is increased morbidity and mortality in children
with seizures and neurodeficits.14,15 This group of patients
tends to have more frequent seizures and often requires
anesthesia for routine procedures (e.g., radiologic examina-
tions and dental examinations and treatment) or proce-
dures related to trauma incurred during a seizure that a
healthy patient otherwise would not require.16
In a recent study at our institution, 24 of 411 patients
(5.8%) with a seizure disorder undergoing regional anes-
thesia experienced postoperative seizure activity, and none
of these seizures were conclusively linked to the regional
technique.8 The overall occurrence of postoperative sei-
zures is slightly lower in our current investigation; how-
ever, it is unclear what factors may have contributed to this
difference, because the anesthetic technique did not seem to
significantly affect the rate of seizure activity. This study
similarly found that patients whose last seizure occurred
close to the time of admission were more likely to experi-
ence a seizure in the perioperative period. In addition,
patients with more frequent seizure activity at baseline
were more likely to have seizure activity during the peri-
operative period.
The retrospective nature of this study creates some
limitations with regard to the recommendations that can be
made based on the results. It is virtually impossible to
retrospectively identify seizure activity in patients under-
going outpatient procedures, thus they were excluded from
our study. However, the risk factors for perioperative
seizures in outpatients are likely to be similar to those
found for hospitalized patients in the perioperative period.
Additionally, the retrospective nature of the study prevents
us from making any specific recommendations regarding
the perioperative management of patients with a seizure
disorder. Both of these issues would require further pro-
spective investigation. The lack of continuous electroen-
cephalographic monitoring in our study may have caused
an underestimation of the overall seizure frequency. In
addition, there may have been patients with nonconvulsive
seizures resulting in prolonged emergence or nocturnal
nonconvulsive seizures that were not identified.
In summary, patients with an underlying seizure disor-
der infrequently experience a perioperative seizure. Pa-
tients with frequent seizures at baseline and with recent
seizures before surgical admission are at increased risk for
perioperative seizure activity. The anesthetic technique
does not seem to have a role in the occurrence of periop-
erative seizures, and most patients who do have a seizure
experience their typical seizure type. The patient’s usual
ANESTHESIA & ANALGESIA
antiepileptic medication regimen should be followed as
closely as possible the day of surgery and while hospital-
ized, with parenteral formulations of the patient’s usual
medications used if gastrointestinal access is contraindi-
cated or if absorption could be affected. The anesthesiologist
should also be prepared to treat seizure activity in the
perioperative setting, particularly in those patients who have
frequent seizures at baseline and those who have experienced
seizure activity close to the time of admission.
ACKNOWLEDGMENTS
This research was conducted as part of the research require-
ment for the Masters of Nurse Anesthesia Program through the
School of Health Related Sciences, Mayo Clinic (for LEA, EJB,
KEN, and JMN).
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