Infratentorial neurosurgery is an independent risk factor for respiratory failure and death in patients undergoing intracranial tumor resection. Mortality is an important contributor to this risk and should be a focus for future research.
To the Editor,We read with interest the recent article by Manji et al. showing the association of tranexamic acid (TXA) with postoperative seizures following cardiac surgery. 1 These data raise important questions about the potential adverse effects of TXA on the central nervous system. The relationship between TXA and seizure activity in populations other than cardiac surgery is undefined. We present a case of postoperative seizure of unclear etiology in a neurosurgical patient who received TXA intraoperatively. The patient provided written consent for publication of this report.A 71-yr-old 122-kg patient with a medical history significant for a congenital solitary kidney (creatinine 133 lmolÁL -1 ) presented to our hospital for an elective right frontotemporal craniotomy and superior orbital osteotomy for resection of a sphenoid wing meningioma. The patient had no history of seizures or raised intracranial pressure preoperatively. Given the risk of significant intraoperative bleeding, he was given 1 g (8 mgÁkg -1 iv) of TXA intraoperatively as a loading dose followed by an infusion of 0.5 gÁhr -1 (4 mgÁkg -1 Áhr -1 ) for the remainder of the case. The estimated blood loss was 1,000 mL. Successful tracheal extubation was performed in the operating room after nine hours of uneventful surgery. Five minutes after arrival in the postanesthesia recovery room, the patient's SpO 2 was observed to be 92%. He then sustained a brief loss of consciousness and a grand mal seizure that progressed to asystolic arrest and five minutes of cardiopulmonary resuscitation, re-intubation, and the administration of epinephrine, sodium bicarbonate, calcium, atropine, and vasopressin before return of spontaneous circulation. Laboratory investigations were significant for lactic acidosis and elevated creatinine (196 lmolÁL -1 ). He was transferred to the intensive care unit for further management, including antiepileptic treatment with propofol and phenytoin. Computed tomography of the patient's head showed no new hemorrhages or infarctions, and electroencephalography performed the following day showed no seizure activity. The patient was successfully weaned from his propofol infusion on the third postoperative day. His postoperative course was complicated by aspiration, prolonged respiratory failure, and deep vein thrombosis. He was transitioned to levetiracetam for the remainder of his hospitalization given the favourable safety and toxicity profile seen with this antiepileptic agent. He was discharged home in satisfactory condition 54 days following surgery.High-dose TXA has recently been associated with an increased incidence of postoperative seizures following cardiac surgery. 1 Potential mechanisms include direct inhibition of glycine and gamma-aminobutyric acid A (GABAa) receptors as well as direct central nervous system toxicity. 2,3 A recent study showed that TXA inhibits glycine receptors to a greater extent than GABAa receptors and that this effect is attenuated by isoflurane and propofol in vitro. 2 Although these data sugg...
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