Profilaxis antiepiléptica en meningiomas: revisión sistemática y metaanálisis

En la actualidad, no existe una indicacion formal de profilaxis anticomicial en neurocirugia oncologica. Tampoco existen recomendaciones especificas sobre el uso de farmacos antiepilepticos (FAE) en pacientes portadores de meningiomas y libres de crisis que van a ser intervenidos. En general, se prescriben FAE de forma discrecional, teniendo en cuenta diversos factores de riesgo clinico-radiologicos. Presentamos una revision sistematica y metaanalisis sobre la efectividad de la profilaxis anticomicial en meningiomas sin historia previa de crisis. Se realizo una busqueda sistematica en las bases de datos PubMed/MEDLINE, Cochrane Central Register of Controlled trials, Embase y clinicaltrials.gov. De los 4.368 estudios inicialmente identificados, finalmente se incluyeron 12 para la extraccion de datos y analisis cualitativo. Los datos clinicos permitieron incluir unicamente 6 estudios en el metaanalisis. Se realizaron estudios de heterogeneidad, calculo de OR combinada, evaluacion del sesgo de publicacion y analisis de sensibilidad. La profilaxis con FAE en meningiomas sin crisis previas no redujo de forma significativa la incidencia de crisis postoperatorias respecto a los controles (OR combinada de Mantle-Haenszel, efectos aleatorios, de 1,26, IC del 95%, 0,60-2,78, sobre 2.041 pacientes). Sin embargo, la ausencia de estudios prospectivos, la presencia de sesgo de seleccion en los estudios, una probable infraestimacion del numero de crisis durante el seguimiento y la influencia marcada de un estudio sobre el efecto global impiden establecer una recomendacion solida en contra de la profilaxis anticomicial. Dentro de las limitaciones de esta revision, los resultados del metaanalisis no apoyan el uso rutinario de la profilaxis antiepileptica en pacientes con meningiomas sin historia previa de crisis. No formal indication currently exists for seizure prophylaxis in neurosurgical oncology patients. Neither have specific recommendations been made on the use of antiepileptic drugs (AED) in seizure-free patients with meningiomas scheduled for surgery. AEDs are generally prescribed on a discretionary basis, taking into consideration a range of clinical and radiological risk factors. We present a systematic review and meta-analysis exploring the effectiveness of antiepileptic prophylaxis in patients with meningioma and no history of seizures. We performed a systematic review of the PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and clinicaltrials.gov databases. Of a total of 4368 studies initially identified, 12 were selected for extraction of data and qualitative analysis. Based on the clinical data presented, we were only able to include 6 studies in the meta-analysis. We performed heterogeneity studies, calculated a combined odds ratio, evaluated publication bias, and conducted a sensitivity analysis. AED prophylaxis in patients with meningioma and no history of seizures did not significantly reduce the incidence of post-operative seizures in comparison to controls (Mantel-Haenszel combined odds ratio, random effects model: 1.26 [95% confidence interval, 0.60-2.78]; 2041 patients). However, we are unable to establish a robust recommendation against this treatment due to the lack of prospective studies, the presence of selection bias in the studies reviewed, the likelihood of underestimation of seizure frequency during follow-up, and the strong influence of one study on the overall effect. Despite the limitations of this review, the results of the meta-analysis do not support the routine use of seizure prophylaxis in patients with meningioma and no history of seizures.