My name is Randalynn Barnett, and I'm a PGY-5 neurosurgery resident at the University of North Carolina in Chapel Hill. Today, I'll be discussing the use of prophylactic antiepileptic administration in the reduction of post-operative seizures following endoscopic third ventriculostomy and choroid plexus cauterization. The Hydrocephalus Clinical Research Network published a study in 2017 that analyzed data on a large and broad cohort of infants treated with ETP-CPC for hydrocephalus. They discovered that the risk of seizure was 5%, primarily occurring in infants less than one month prior to gestational age. In our cohort, however, we discovered a significantly higher incidence of seizures of 27%. In addition, since previous studies have shown that seizures are a significant predictor of poor quality of life in patients with hydrocephalus, we felt that this was important to explore further and try to identify other factors that may be involved, as well as methods of prevention. We conducted a retrospective analysis of 33 patients who underwent ETP-CPC for treatment of their hydrocephalus from 2016 to 2020. We collected data on age, hydrocephalus etiology, operative details, presence of post-operative seizures, seizure semiology, EEG data, imaging characteristics, use of perioperative prophylactic antiepileptic medications, brain thickness, preoperative labs, and medical history. The presence of post-operative seizures was defined as clinical seizures occurring within 24 hours of surgery. In our ETP-CPC cohort, the most common etiologies of hydrocephalus were aqueductal stenosis, myelomeningoceles, and post-hemorrhagic hydrocephalus. Three out of seven patients who had aqueductal stenosis experienced post-operative seizures. Three out of seven of our prenatally repaired myelomeningocele patients developed seizures following surgery. Two out of seven of our postnatally repaired myelomeningocele patients had post-operative seizures, and only one out of four patients with post-hemorrhagic hydrocephalus developed seizures following surgery. In our study, we looked at several different parameters in relation to seizure status, including administration of prophylactic perioperative kephra, age at time of surgery, brain thickness at the site of the tract of the scope, head circumference at time of surgery, type of scope utilized, operative time, and preoperative electrolyte labs. We found that the use of prophylactic kephra had a statistically significant association with seizure status. 27% of our cohort developed clinical seizures post-operatively, 15% of which had electrographically captured seizures on EEG. 47% of patients who did not receive prophylactic perioperative kephra developed seizures post-operatively. Starting in mid-2018, 14 patients of our cohort received kephra at the start of surgery and maintenance dosing for the following seven days. Out of these patients, 0% developed post-operative seizures, which was significantly lower than what we had previously seen prior to giving kephra. There were several limitations within our study, including that our data is representative of a single institutional experience, with a small cohort of only 33 patients. In addition, kephra administration was non-randomized, and began in mid-2018. The results of our study suggest that the use of perioperative kephra may be efficacious in preventing post-operative seizures following ETVCBC. Studies with larger sample sizes are necessary to further investigate what other factors may play a role in seizure development following ETVCBC and how to prevent them. Further investigations should also consider the routine use of EEG post-operatively to detect and study patterns of subclinical and clinical seizures following ETVCBC. I would like to thank Dr. Carolyn Quincy and Dr. Scott Elton for their valuable mentorship throughout my residency training and in this research. I would also like to give thanks to Drs. Angela Oboya and Valerie Jules, as well as medical students Allie Harbour and Gammy Pager for their significant contributions to this study.

neurosurgery resident

prophylactic antiepileptic administration

post-operative seizures

endoscopic third ventriculostomy and choroid plexus cauterization

infants with hydrocephalus