Seizures and epilepsy in patients with a spontaneous intracerebral haematoma

Risk factors of posthemorrhagic seizure in spontaneous intracerebral hemorrhage

Seizure is a relatively common neurological consequence after spontaneous intracerebral hemorrhage (SICH). This study aimed to investigate risk factors of early, late, and overall seizures in patients with SICH. Retrospective analysis was performed on all patients with SICH who completed two years of follow-up. The variables collected were obtained from demographic, clinical, radiographic and treatment data, in-hospital complications, and follow-up results. Univariate and multivariate analyzes were used to identify risk factors for post-hemorrhagic stroke seizure. Of 400 SICH patients recruited, 30 (7.5%) and 40 (10%) developed early and late seizures during the 2-year follow-up period, respectively. In the final result of the multivariate analysis, factors associated with the occurrence of the early seizure included lobar location of hematoma (p = 0.018), and GCS ≤ 12 on initial clinical presentation (p = 0.007). Factors associated with the occurrence of the late seizure included lobar location of hematoma (p = 0.001), volume of hematoma greater than 10 ml (p = 0.009), and midline shift on initial cranial CT (p = 0.036). Risk factors of the overall seizure after SICH included lobar location of hematoma (p < 0.001), volume of hematoma greater than 10 ml (p < 0.001), and craniotomy with evacuation of hematoma (p = 0.007). Furthermore, seizure was also associated with a poor functional outcome 2 years after the onset of SICH. Several factors associated with the appearance of post-ICH seizures were revealed. In patients with increased risk of post-SICH seizures, appropriate surveillance and management of seizures should be carried out.

EEG and semiology in the elderly: A systematic review

INTRODUCTION

The prevalence and incidence of epileptic seizures and epilepsy increases among the elderly. Epileptic seizures in older people remain often unreported and undiagnosed, contributing to incorrect or delayed treatment. The goal of our review paper is to increase awareness of seizures in the elderly, to improve the diagnostic process in this growing population.

METHODS

We present a systematic review of the literature on EEG findings and seizure semiology among the elderly according to the PRISMA statement. One hundred and two original studies were included and findings were divided in four groups: EEG among elderly without seizures, EEG among elderly with seizures or epilepsy, semiology, and status epilepticus.

CONCLUSIONS

EEG abnormalities are found in approximately half of the geriatric population referred to routine EEG. Slowing (both focal and diffuse) is the most common finding among seniors with and without seizures. Interictal epileptiform discharges (IEDs) are likewise seen among healthy seniors, which reduces their specificity as biomarker for epilepsy. Focal onset seizures prevail among the aged. Generalized seizures are uncommon, starting usually earlier in life but exacerbating in later years. Motor phenomena are less frequently seen than among younger individuals. Seizures are mainly characterized by impairment of awareness, disturbed cognition and confusion, both ictally and postictally. Unresponsiveness may occur during non-epileptic events too, which further challenges seizure recognition. Epilepsy and dementia are bi-directionally related: dementia carries an increased risk of developing epilepsy and vice versa. Up to 45 % of the aged with new onset seizures present with status epilepticus (SE). SE among the elderly is more often focal motor; non-convulsive status epilepticus (NSCE) constitutes 10-25 %.

Predictors of unprovoked seizures in intracerebral hemorrhages

BACKGROUND

Seizures are a common complication of intracerebral hemorrhage (ICH). We aimed to identify predictors of unprovoked seizures (US) after ICH in a Chinese cohort.

METHODS

We retrospectively included patients with ICH admitted in the Second Hospital of Hebei Medical University between November 2018 and December 2020. Incidence and risk factors of US were identified with univariate and then multiple Cox regression analysis. We used χ2 test to compare incidence of US between groups with or without prophylactic anti-seizure medications (ASM) in patients with craniotomy.

RESULTS

A total of 488 patients were included in the cohort, 58 (11.9%) patients developed US within 3 years after ICH. Analysis on the 362 patients without prophylactic ASM showed that craniotomy (HR 8.35, 95% CI 3.80-18.31) and acute symptomatic seizures (ASS) (HR 13.76, 95% CI 3.56-53.17) are independent predictors of US. No significant effect of prophylactic ASM use was found on incidence of US in ICH patients with craniotomy (P = 0.369).

CONCLUSIONS

Craniotomy and acute symptomatic seizures were independent predictors for unprovoked seizures after ICH, suggesting that more attention should be paid for such patients during follow-up. Whether prophylactic ASM treatment benefits ICH patients underwent craniotomy remains uncertain.

Effect of Primary Prophylactic Antiseizure Medication for Seizure Prevention Following Intracerebral Hemorrhage in the ERICH Study

OBJECTIVES

Intracerebral hemorrhage (ICH) has the highest morbidity and mortality rate of any stroke subtype and clinicians often administer prophylactic antiseizure medications (ASMs) as a means of preventing post-stroke seizures, particularly following lobar ICH. However, evidence for ASM efficacy in preventing seizures and reducing disability is lacking given limited randomized trials. Herein, we report analysis from a large prospective observational study that evaluates the effect of primary prophylactic ASM administration on seizure occurrence and disability following ICH.

MATERIALS AND METHODS

Primary analysis was performed on 1630 patients with ICH enrolled in the ERICH study. A propensity score for administration of prophylactic ASM was developed and patients were matched by the closest propensity score (difference < 0.1). McNemar's test was used to compare occurrence of in-hospital seizure and disability, defined by modified Rankin Score (mRS) ≥ 3 at 3 months post ICH.

RESULTS

Of the 815 matched pairs of patients treated with primary prophylactic ASM, there was no significant difference in seizure occurrence (p = 0.4631) or disability (p = 0.4653). Subset analysis of 280 matched pairs of patients with primary lobar ICH similarly revealed no significant difference in seizure occurrence (p = 0.1011) or disability (p = 1.00) between prophylactically treated and untreated patients.

CONCLUSIONS

Although current guidelines do not recommend primary prophylactic ASM following ICH, clinical use remains widespread. Data from the ERICH study did not find an association between administering primary prophylactic ASM and preventing seizures or reducing disability following ICH, thus providing evidence to influence clinical practice and patient care.

Incidence rate and risk factors of status epilepticus after stroke

Purpose To evaluate the incidence rate and risk factors for status epilepticus (SE) after stroke (PSSE), including ischaemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH). Methods A meta-analysis was performed using relevant research from databases such as PubMed, Embase, Cochrane Online Library, and Clinicaltrials.gov. The quality of the studies was evaluated by using the quality evaluation criteria of the Agency for Healthcare Research and Quality (AHRQ). All data were pooled by STATA 12.0 software for meta-analysis. Results The review considered 1650 articles, and 17 articles with 2821 instances of SE among 1088087 instances of stroke were included. The incidence rate of SE after stroke was 6.90 per 1000 total strokes (95% CI: 5.58-8.22). By subgroup analysis of SE, the rates were 33.85‰ (95% CI: 13.77-53.94) for non-convulsive status epilepticus (NCSE) and 2.42‰ (95%CI: 1.66-3.19) for generalized convulsive status epilepticus (GCSE). Age, sex, and presence of atrial fibrillation showed no significant difference between the SE group and the non-SE group after stroke. Hypertension and diabetes are associated with a decreased rate of SE. However, African American race, alcohol abuse, and renal disease are associated with an increased rate of SE. Significance There were approximately 6.9 patients with status epilepticus per 1000 strokes. NCSE is more common after stroke and needs more attention. African American race, alcohol abuse and renal disease may be risk factors for PSSE.

Development and validation of a clinical score to predict late seizures after intracerebral hemorrhage in Chinese

BACKGROUND

Seizures are a frequent complication after intracerebral hemorrhage (ICH). The CAVE score was developed in Europeans to predict late seizures after ICH. Given the higher incidence of ICH in Asians, we aimed to develop and validate a clinical scoring tool for predicting post-ICH late seizures in Chinese.

METHODS

We retrospectively included patients admitted with ICH to a major stroke center in Shandong province, China, in the derivation cohort, who were followed up for occurrence of late seizures (more than seven days after ICH). We applied Cox regression model to identify significant clinical factors which were used to derive a predictive scoring model. The performance of this model was compared with CAVE, and validated in a separate cohort of patients with ICH admitted to another stroke center.

RESULTS

In the derivation cohort (n = 602; median age 65 years; 57 % male；median follow up 24 months), 47 (7.8 %) patients had late seizures during follow up. Four significant risk factors were identified and selected to derive the LANE score (Lobar hemorrhage, Age <65 years, NIHSS score ≥15, Early seizures). The total possible points ranged from 0 to 6, corresponding to positive predictive values of 10.1%-100%, and negative predictive values of 96.8%-92.2%, respectively. The c-statistics of the LANE score in the derivation cohort and validation cohort (n = 521) were 0.83 and 0.78, respectively, while those of the CAVE score were 0.81 and 0.74, respectively.

CONCLUSION

We have developed and validated a clinical scoring tool for predicting late seizures after ICH in Chinese. This tool may be used to identify high risk patients for closer monitoring and clinical trials of therapies to prevent post-ICH epilepsy in the future.

Occipital intracerebral hemorrhage-clinical characteristics, outcome, and post-ICH epilepsy

OBJECTIVES

Posterior location affects the clinical presentation and outcome of ischemic stroke, but little is known about occipital intracerebral hemorrhage (ICH). We studied non-traumatic occipital ICH phenotype, outcome, and post-ICH epilepsy.

MATERIALS AND METHODS

Occipital ICH patients were retrospectively identified from the Helsinki ICH Study registry of 1013 consecutive ICH patients treated in our tertiary center in 2005-2010. They were compared to non-occipital ICH patients to evaluate the effect of location on functional outcome at discharge (dichotomized modified Rankin Scale, mRS), 3- and 12-month mortality, and incidence of epilepsy.

RESULTS

We found 19 occipital ICH patients (5.3% of lobar and 1.9% of all ICH). Compared to non-occipital lobar ICHs, they were younger (median age 63 vs 71 years, P = .007) and had lower National Institutes of Health Stroke Scale on admission (1 vs 8, P < .001), smaller hematoma volume (6.3 vs 17.7 ML, P = .008), and more frequently structural etiology underlying the ICH (26% vs 7%, P = .01). Mortality at both 3 and 12 months was 6%, whereas 84% reached favorable outcome (mRS 0-2) at discharge. Occipital location was associated with favorable outcome at discharge in lobar ICH (OR 11.02, 95% CI 1.55-78.20). Incidence of post-ICH epilepsy (median follow-up 2.7 years) was 18%, equaling to that of non-occipital lobar ICH.

CONCLUSIONS

Occipital ICH patients are younger, have less severe clinical presentation, smaller hematoma volume, more often structural etiology, and better outcome than other ICH patients. They exhibit a similar risk of epilepsy as non-occipital ICHs.

Ictal-interictal continuum: a review of recent advancements

Continuous electroencephalogram (cEEG) has become an indispensable technique in the management of critically ill patients for early detection and treatment of non-convulsive seizures (NCS) and non-convulsive status epilepticus (NCSE). It has also brought about a renaissance in a wide range of rhythmic and periodic patterns with heterogeneous frequency and morphology. These patterns share the rhythmic and sharp appearances of electrographic seizures, but often lack the necessary frequency, spatiotemporal evolution and clinical accompaniments to meet the definitive criteria for ictal patterns. They may be associated with cerebral metabolic crisis and neuronal injury, therefore not clearly interictal either, but lie along an intervening spectrum referred to as ictal-interictal continuum (IIC). Generally speaking, rhythmic and periodic patterns are categorized as interictal patterns when occurring at a rate of <1Hz, and are categorized as NCS and NCSE when occurring at a rate of >2.5 Hz with spatiotemporal evolution. As such, IIC commonly includes the rhythmic and periodic patterns occurring at a rate of 1–2.5 Hz without spatiotemporal evolution and clinical correlates. Currently there are no evidence-based guidelines on when and if to treat patients with IIC patterns, and particularly how aggressively to treat, presenting a challenging electrophysiological and clinical conundrum. In practice, a diagnostic trial with preferably a non-sedative anti-seizure medication (ASM) can be considered with the end point being both clinical and electrographic improvement. When available and necessary, correlation of IIC with biomarkers of neuronal injury, such as neuronal specific enolase (NSE), neuroimaging, depth electrode recording, cerebral microdialysis and oxygen measurement, can be assessed for the consideration of ASM treatment. Here we review the recent advancements in their clinical significance, risk stratification and treatment algorithm.

Electrographic seizures and ictal-interictal continuum (IIC) patterns in critically ill patients

Critical care long-term continuous electroencephalogram (cEEG) monitoring has expanded dramatically in the last several decades spurned by technological advances in EEG digitalization and several key clinical findings: 1-Seizures are relatively common in the critically ill-large recent observational studies suggest that around 20% of critically ill patients placed on cEEG have seizures. 2-The majority (~75%) of patients who have seizures have exclusively "electrographic seizures", that is, they have no overt ictal clinical signs. Along with the discovery of the unexpectedly high incidence of seizures was the high prevalence of EEG patterns that share some common features with archetypical electrographic seizures but are not uniformly considered to be "ictal". These EEG patterns include lateralized periodic discharges (LPDs) and generalized periodic discharges (GPDs)-patterns that at times exhibit ictal-like behavior and at other times behave more like an interictal finding. Dr. Hirsch and colleagues proposed a conceptual framework to describe this spectrum of patterns called the ictal-interictal continuum (IIC). In the following years, investigators began to answer some of the key pragmatic clinical concerns such as which patients are at risk of seizures and what is the optimal duration of cEEG use. At the same time, investigators have begun probing the core questions for critical care EEG-what is the underlying pathophysiology of these patterns, at what point do these patterns cause secondary brain injury, what are the optimal treatment strategies, and how do these patterns affect clinical outcomes such as neurological disability and the development of epilepsy. In this review, we cover recent advancements in both practical concerns regarding cEEG use, current treatment strategies, and review the evidence associating IIC/seizures with poor clinical outcomes.

Risk factors for seizures after intracerebral hemorrhage: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study

OBJECTIVE

We aimed to identify risk factors for seizures after intracerebral hemorrhage, and to validate the prognostic value of the previously reported CAVE score (0-4 points: cortical involvement, age <65, volume >10 mL, and early seizures within 7 days of hemorrhage).

PATIENTS AND METHODS

Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) was a prospective study of spontaneous intracerebral hemorrhage. We included patients who did not have a prior history of seizure and survived to discharge. Univariate analysis and multiple logistic regression modeling were used to identify risk factors for seizure.

RESULTS

From 2010-2015, 3000 cases were recruited, and 2507 patients were included in this study. Seizures after hospital discharge developed in 77 patients 3.1 %). Patients with lobar (cortical) hemorrhage (OR 3.0, 95 % CI 1.8-5.0), larger hematoma volume (OR 1.5 per cm³, 95 % CI 1.2-2.0), and surgical evacuation of hematoma (OR 2.6, 95 % CI 1.4-4.8) had a higher risk of late seizure, and older patients had a lower risk (OR 0.88 per 5-year interval increase, 95 % CI 0.81-0.95). The CAVE score was highly associated with seizure development (OR 2.5 per unit score increase, 95 % CI 2.0-3.2, p < 0.0001). The CAVS score, substituting surgical evacuation for early seizure, increased the OR per unit score to 2.8 (95 % CI 2.2-3.5).

CONCLUSIONS

Lobar hemorrhage, larger hematoma volume, younger age, and surgical evacuation are strongly associated with the development of seizures. We validated the CAVE score in a multi-ethnic population, and found the CAVS score to have similar predictive value while representing the current practice of AED use.

Impact of antiepileptic drugs for seizure prophylaxis on short and long-term functional outcomes in patients with acute intracerebral hemorrhage: A meta-analysis and systematic review

PURPOSE

The purpose of this analysis is to assess the effect of antiepileptics (AEDs) on seizure prevention and short and long term functional outcomes in patients with acute intracerebral hemorrhage.

METHOD

The meta-analysis was conducted using the PRISMA guidelines. A literature search was performed of the PubMed, the Cochrane Library, and EMBASE databases. Search terms included "Anticonvulsants", "Intracerebral Hemorrhage", and related subject headings. Articles were screened and included if they were full-text and in English. Articles that did not perform multivariate regression were not included. Overall effect size was evaluated with forest plots and publication bias was assessed with the Begg's and Egger's tests.

RESULTS

A total of 3912 articles were identified during the initial review. After screening, 54 articles remained for full review and 6 articles were included in the final analysis. No significant association between the use of AEDs after ICH and functional outcome (OR 1.53 [95%CI: 0.81-2.88] P = 0.18, I² = 81.7%). Only one study evaluated the effect AEDs had in preventing post-ICH seizures.

CONCLUSIONS

The use of prophylactic AEDs was not associated with improved short and long outcomes after acute ICH. This analysis supports the 2015 AHA/ASA recommendation against prophylactic AEDs (class III; level of evidence b).

Ictal vomiting after cerebellar hemorrhage: A case report

Vomiting is a typical symptom of cerebellar hemorrhage. Usually only supportive care such as antiemetic drugs are available. A 76-year-old woman presented in a light coma. A head CT demonstrated right cerebellar hemorrhage and the hematoma was surgically evacuated. Her intractable vomiting started 3 weeks after surgery. Because her vomiting was unexplained, we checked her EEG, which demonstrated generalized periodic discharges. We diagnosed her with ictal vomiting. Anti-seizure medication was administered and vomiting was rapidly controlled. In conclusion, physicians must be aware that vomiting may rarely occur as a sign of seizures and status epilepticus.

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Ictal vomiting is one of the clinical presentations of status epilepticus.

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Cerebellar hemorrhage is also cause of ictal vomiting.

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EEG demonstrates periodic discharges.

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Adequate antiepileptic drug may ameliorate ictal vomiting.

Poststroke epilepsy in long-term survivors of primary intracerebral hemorrhage

OBJECTIVE

To identify the incidence and predisposing factors for development of poststroke epilepsy (PSE) after primary intracerebral hemorrhage (PICH) during a long-term follow-up.

METHODS

We performed a retrospective study of patients who had had their first-ever PICH between January 1993 and January 2008 in Northern Ostrobothnia, Finland, and who survived for at least 3 months. These patients were followed up for PSE. The associations between PSE occurrence and sex, age, Glasgow Coma Scale (GCS) score on admission, hematoma location and volume, early seizures, and other possible risk factors for PSE were assessed using the Cox proportional hazards regression model.

RESULTS

Of the 615 PICH patients who survived for longer than 3 months, 83 (13.5%) developed PSE. The risk of new-onset PSE was highest during the first year after PICH with cumulative incidence of 6.8%. In univariable analysis, the risk factors for PSE were early seizures, subcortical hematoma location, larger hematoma volume, hematoma evacuation, and a lower GCS score on admission, whereas patients with infratentorial hematoma location or hypertension were less likely to develop PSE (all variables p < 0.05). In multivariable analysis, we found subcortical location (hazard ratio [HR] 2.27, 95% confidence interval [CI] 1.35-3.81, p < 0.01) and early seizures (HR 3.63, 95% CI 1.99-6.64, p < 0.01) to be independent risk factors, but patients with hypertension had a lower risk of PSE (HR 0.54, 0.35-0.84, p < 0.01).

CONCLUSIONS

Subcortical hematoma location and early seizures increased the risk of PSE after PICH in long-term survivors, while hypertension seemed to reduce the risk.

Delayed seizures after intracerebral haemorrhage

Late seizures after intracerebral haemorrhage occur after the initial acute haemorrhagic insult subsides, and represent one of its most feared long-term sequelae. Both susceptibility to late seizures and their functional impact remain poorly characterized. We sought to: (i) compare patients with new-onset late seizures (i.e. delayed seizures), with those who experienced a recurrent late seizure following an immediately post-haemorrhagic seizure; and (ii) investigate the effect of late seizures on long-term functional performance after intracerebral haemorrhage. We performed prospective longitudinal follow-up of consecutive intracerebral haemorrhage survivors presenting to a single tertiary care centre. We tested for association with seizures the following neuroimaging and genetic markers of cerebral small vessel disease: APOE variants ε2/ε4, computer tomography-defined white matter disease, magnetic resonance imaging-defined white matter hyperintensities volume and cerebral microbleeds. Cognitive performance was measured using the Modified Telephone Interview for Cognitive Status, and functional performance using structured questionnaires obtained every 6 months. We performed time-to-event analysis using separate Cox models for risk to develop delayed and recurrent seizures, as well as for functional decline risk (mortality, incident dementia, and loss of functional independence) after intracerebral haemorrhage. A total of 872 survivors of intracerebral haemorrhage were enrolled and followed for a median of 3.9 years. Early seizure developed in 86 patients, 42 of whom went on to experience recurrent seizures. Admission Glasgow Coma Scale, increasing haematoma volume and cortical involvement were associated with recurrent seizure risk (all P < 0.01). Recurrent seizures were not associated with long-term functional outcome (P = 0.67). Delayed seizures occurred in 37 patients, corresponding to an estimated incidence of 0.8% per year (95% confidence interval 0.5-1.2%). Factors associated with delayed seizures included cortical involvement on index haemorrhage (hazard ratio 1.63, P = 0.036), pre-haemorrhage dementia (hazard ratio 1.36, P = 0.044), history of multiple prior lobar haemorrhages (hazard ratio 2.50, P = 0.038), exclusively lobar microbleeds (hazard ratio 2.22, P = 0.008) and presence of ≥ 1 APOE ε4 copies (hazard ratio 1.95, P = 0.020). Delayed seizures were associated with worse long-term functional outcome (hazard ratio 1.83, P = 0.005), but the association was removed by adjusting for neuroimaging and genetic markers of cerebral small vessel disease. Delayed seizures after intracerebral haemorrhage are associated with different risk factors, when compared to recurrent seizures. They are also associated with worse functional outcome, but this finding appears to be related to underlying small vessel disease. Further investigations into the connections between small vessel disease and delayed seizures are warranted.

Status epilepticus in adults

Status epilepticus is a common neurological emergency with considerable associated health-care costs, morbidity, and mortality. The definition of status epilepticus as a prolonged seizure or a series of seizures with incomplete return to baseline is under reconsideration in an effort to establish a more practical definition to guide management. Clinical research has focused on early seizure termination in the prehospital setting. The approach of early escalation to anaesthetic agents for refractory generalised convulsive status epilepticus, rather than additional trials of second-line anti-epileptic drugs, to avoid neuronal injury and pharmaco-resistance associated with prolonged seizures is gaining momentum. Status epilepticus is also increasingly identified in the inpatient setting as the use of extended electroencephalography monitoring becomes more commonplace. Substantial further research to enable early identification of status epilepticus and efficacy of anti-epileptic drugs will be important to improve outcomes.

Subarachnoid extension of hemorrhage is associated with early seizures in primary intracerebral hemorrhage

BACKGROUND

Seizures are common in patients with subarachnoid hemorrhage, potentially by inciting cortical irritability. Seizures are also commonly seen after intracerebral hemorrhage (ICH), although the mechanisms and risk factors within that population are not well understood. The objective of this study is to evaluate whether subarachnoid hemorrhage extension (SAHE) is associated with early seizures in patients with primary ICH.

METHODS

Patients with primary ICH were enrolled into a prospective registry between December 2006 and July 2012. Patients were managed per a structured protocol. SAHE was identified on imaging by expert reviewers blinded to outcomes. Electroencephalograms were routinely obtained in patients with unexplained, poor level of arousal. Seizure was determined by clinically observed convulsions or traditional electroencephalographic criteria. Early seizures were defined as occurring within 3 days of hemorrhage. A binary logistic regression model was developed to test whether the occurrence of SAHE was independently associated with seizures.

RESULTS

A total of 234 patients were studied. Of these, 93 (40%) had SAHE and 9 (4%) had early seizures. SAHE was associated with early seizures (P = .03). No additional variables were identified by regression modeling to mediate the association between SAHE and early seizures (odds ratio 5.62 [95% confidence interval 1.14-27.7], P = .034).

CONCLUSIONS

SAHE is associated with early seizures in patients with primary ICH. Further study is needed to confirm these findings and determine whether modifications to routine care based on the presence of SAHE would be of benefit.

The CAVE score for predicting late seizures after intracerebral hemorrhage

BACKGROUND AND PURPOSE

Seizures are a common complication of intracerebral hemorrhage (ICH). We developed a novel tool to quantify this risk in individual patients.

METHODS

Retrospective analysis of the observational Helsinki ICH Study (n=993; median follow-up, 2.7 years) and the Lille Prognosis of InTra-Cerebral Hemorrhage (n=325; 2.2 years) cohorts of consecutive ICH patients admitted between 2004 and 2010. Helsinki ICH Study patients' province-wide electronic records were evaluated for early seizures occurring within 7 days of ICH and among 7-day survivors (n=764) for late seizures (LSs) occurring >7 days from ICH. A Cox regression model estimating risk of LSs was used to derive a prognostic score, validated in the Prognosis of InTra-Cerebral Hemorrhage cohort.

RESULTS

Of the Helsinki ICH Study patients, 109 (11.0%) had early seizures within 7 days of ICH. Among the 7-day survivors, 70 (9.2%) patients developed LSs. The cumulative risk of LSs was 7.1%, 10.0%, 10.2%, 11.0%, and 11.8% at 1 to 5 years after ICH, respectively. We created the CAVE score (0-4 points) to estimate the risk of LSs, with 1 point for each of cortical involvement, age<65 years, volume>10 mL, and early seizures within 7 days of ICH. The risk of LSs was 0.6%, 3.6%, 9.8%, 34.8%, and 46.2% for CAVE scores 0 to 4, respectively. The c-statistic was 0.81 (0.76-0.86) and 0.69 (0.59-0.78) in the validation cohort.

CONCLUSIONS

One in 10 patients will develop seizures after ICH. The risk of this adverse outcome can be estimated by a simple score based on baseline variables.

Immediate, early and late seizures after primary intracerebral hemorrhage

BACKGROUND

Seizures after primary intracerebral hemorrhage (PICH) are significant and treatable complications, but the factors predicting immediate, early and late seizures are poorly known. We investigated characteristics and outcome with special reference to occurrence and timing of a first seizure among consecutive subjects with PICH.

METHODS

A population-based study was conducted in Northern Ostrobothnia, Finland, in 1993-2008 that included all patients with a first-ever primary ICH without any prior diagnosis of epilepsy. Immediate (<24h after admission), early (1-14 days) and late (>2 weeks) seizures were considered separately.

RESULTS

Out of a total of 935 ICH patients, 51 had immediate, 21 early and 58 late seizures. The patients with seizures were significantly younger than the others and more often had a subcortical hematoma location (p<0.05). Lifestyle factors did not differ between the groups. The risk factors for immediate seizures in multivariable analysis were a low Glasgow coma scale score (GCS) on admission, subcortical location and age inversely (p<0.01). The only independent risk factor for early seizures was subcortical location (p<0.001), whereas subcortical location (p<0.001), age inversely (p<0.01) and hematoma evacuation (p<0.05) independently predicted late seizures. Immediate and early seizures predicted infectious complications (p<0.05).

CONCLUSIONS

Patients with subcortical hematoma and of younger age are at risk for immediate seizures after primary ICH irrespective of hematoma size. Patients with immediate and early seizures more often had infectious complications. Surgery increases the risk of a late seizure after ICH.

Epidemiological and clinical characteristics of 266 cases of intracerebral hemorrhage in Hangzhou, China

Ethnicity and socioeconomic factors can influence disease susceptibility, clinical presentation, and outcome. We investigated the clinical characteristics (age, sex, seasonal variation, lesion site, symptoms, complications, prognosis, and sequelae) and risk factors for intracerebral hemorrhage (ICH) in 266 cases treated at our hospital in Hangzhou City, China, from January 2011 to December 2011. Risk of ICH increased dramatically with age; only 4.3% of cases were <30 years old, while 44.4% were >60 years of age. Men outnumbered women by 2:1 (67.3% vs. 32.7%). Single hemorrhage was most often located in the cerebral lobes (37.2% of cases), basal ganglia (34.2%), thalamus (8.3%), cerebellum (6.8%), ventricle (1.5%), and brainstem (1.1%), while 10.9% of cases exhibited hemorrhages at multiple sites. Hypertension was also a major risk factor for ICH, as 47% of all patients were hypertensive and the percentage increased with age. In hypertensive patients, the most common hemorrhage site was the basal ganglia and ICH was often associated with thrombopenia. In patients with leukemia (all forms), most hemorrhages were lobar. Warfarin- and encephalic operation-associated ICHs were all lobar. Headache was the major symptom of occipital, temporal, and frontal lobe hemorrhage. Dizziness, nausea, and vomiting were the major symptoms of cerebellum hemorrhage. Limb dysfunction was the major symptom of thalamic and basal ganglia hemorrhage. Disturbed level of consciousness was the major symptom in multisite, ventricular, parietal lobe, and brainstem hemorrhage. Hyperspasmia occurred most often in lobar hemorrhage and blurred vision in occipital lobe hemorrhage. Hospital mortality was 24.4% (n=65) with a mean delay from presentation to death of (10.5±18.5) d. The majority of fatalities were cerebral hernia cases (58.5%) and these patients also had the shortest time to death [(2.9±3.5) d]. Mortality was 100% in brainstem ICH and hemorrhagic conversion of cerebral infarct. Thrombopenia-associated ICH also had a high mortality rate (81.0%), while patients with cerebrovascular malformations and cerebral aneurysms demonstrated a much better prognosis (46.2% recovery).

Continuous electroencephalographic monitoring in critically ill patients: indications, limitations, and strategies

OBJECTIVE

Continuous electroencephalography as a bedside monitor of cerebral activity has been used in a range of critically ill patients. This review compiles the indications, limitations, and strategies for continuous electroencephalography in the ICU.

DATA SOURCE

The authors searched the electronic MEDLINE database.

STUDY SELECTION AND DATA EXTRACTION

References from articles of special interest were selected.

DATA SYNTHESIS AND CONCLUSION

Electroencephalographically-defined suppression is routinely used as the basis for titration of pharmacologic therapy in refractory status epilepticus and intracranial hypertension. The increasing use of continuous electroencephalography reveals a clinically underappreciated burden of epileptiform and epileptic activity in patients with primary acute neurologic disorders, and also in critically ill patients with acquired encephalopathy. Status epilepticus is reported with continuous electroencephalography in 1% to 10% of patients with ischemic stroke, 8% to 14% with traumatic brain injury, 10% to 14% with subarachnoid hemorrhage, 1% to 21% with intracerebral hemorrhage, and 30% of patients following cardiorespiratory arrest. These figures underscore the importance of continuous electroencephalography in the critically ill. The interpretation of continuous electroencephalography in the ICU is challenged by electroencephalography artifacts and the frequent subtle differences between ictal and interictal patterns.

Seizures after spontaneous intracerebral hemorrhage

Objective

In patients with spontaneous intracerebral hemorrhage (ICH), the risk factors for seizure and the effect of prophylactic anticonvulsants are not well known. This study aimed to determine the risk factor for seizures and the role for prophylactic anticonvulsants after spontaneous ICH.

Methods

Between 2005 and 2010, 263 consecutive patients with spontaneous ICH were retrospectively assessed with a mean follow-up of 19.5 months using medical records, updated clinical information and, when necessary, direct patient contact. The seizures were classified as early (within 1 week of ICH) or late (more than 1 week after ICH). The outcomes were measured with the Glasgow Outcome Scale at discharge and the modified Rankin Scale (mRS) at both 2 weeks and discharge.

Results

Twenty-two patients (8.4%; 9 patients with early seizures and 13 patients with late seizures) developed seizures after spontaneous ICH. Out of 263 patients, prophylactic anticonvulsants were administered in 216 patients. The prophylactic anticonvulsants were not associated with a reduced risk of early (p=0.094) or late seizures (p=0.326). Instead, the factors associated with early seizure were cortical involvement (p<0.001) and younger age (60 years or less) (p=0.046). The risk of late seizure was increased by cortical involvement (p<0.001) and communicating hydrocephalus (p=0.004). The prophylactic anticonvulsants were associated with a worse mRS at 2 weeks (p=0.024) and at last follow-up (p=0.034).

Conclusion

Cortical involvement may be a factor for provoked seizures. Although the incidence of early seizures tended to decrease in patients prescribed prophylactic anticonvulsants, no statistical difference was found.

[Stroke care in the ICU: general supportive treatment. Experts' recommendations]

The French Society of Intensive Care (SRLF) requested medical experts to publish recommendations on the management of stroke in the ICU for adult and pediatric patients. The following article describes the underlying evidence used by the experts to elaborate recommendations for general supportive treatment. Such treatment is fundamental for victims of acute stroke to avoid neurological worsening. Oxygen delivery in a normoxic patient is useless. However, if saturation is below 92 %, oxygen supplementation is needed. Hyper- and hypoglycemia worsen the neurological prognosis. As no glycemic target is known, administration of insulin is required for glucose levels higher that 10 mmol/l. Body temperature above 37.5° is associated with poorer outcome. In the acute phase of stroke, high blood pressure should not be lowered except in life-threatening situations, and if so the lowering should be done cautiously. The current consensus is to lower blood pressure if the systolic pressure is above 220 mmHg or if the diastolic pressure is above 120 mmHg for ischemic stroke. For hemorrhagic stroke and after thrombolysis, treatment is needed if systolic pressure rises above 180 mmHg and if diastolic pressure is above 105 mmHg. Small doses of heparin decrease the risk of deep venous thrombosis and pulmonary embolism without increasing cerebral bleeding. There is no consensus on the treatment of epileptic crises after stroke and no dedicated treatment. Further studies are needed to define adequate blood pressure and glycemic target values in order to limit secondary worsening after an acute stroke as well as the appropriate modalities for the treatment of epilepsy.

Complications of intracerebral haemorrhage

Intracerebral haemorrhage (ICH) is the most devastating type of stroke and is a leading cause of disability and mortality. By contrast with advances in ischaemic stroke treatment, few evidence-based targeted treatments exist for ICH. Management of ICH is largely supportive, with strategies aimed at the limitation of further brain injury and the prevention of associated complications, which add further detrimental effects to an already lethal disease and jeopardise clinical outcomes. Complications of ICH include haematoma expansion, perihaematomal oedema with increased intracranial pressure, intraventricular extension of haemorrhage with hydrocephalus, seizures, venous thrombotic events, hyperglycaemia, increased blood pressure, fever, and infections. In view of the restricted number of therapeutic options for patients with ICH, improved surveillance is needed for the prevention of these complications, or, when this is not possible, early detection and optimum management, which could be effective in the reduction of adverse effects early in the course of stroke and in the improvement of prognosis. Further studies are needed to enhance the evidence-based recommendations for the management of this important clinical problem.

Cerebral paragonimiasis that manifested as intracranial hemorrhage

OBJECT

The purpose of this study was to review 14 rare cases of cerebral paragonimiasis that first manifested as intracranial hemorrhage (ICH), and to investigate the characteristics of clinical manifestation, diagnosis, and treatment of the disease.

METHODS

The authors have encountered 14 cases of cerebral paragonimiasis in patients between the ages of 6 and 16 years (mean age 11.5 years) who presented with sudden headache, nausea, and vomiting. Three of them were affected with varying degrees of limb hemiplegia, and in 1 this was combined with high fever; the blood eosinophil count and enzyme-linked immunosorbent assay showed positive results too. The ICHs were observed with cranial CT and MR imaging, and lung lesions were also detected in 5 cases on chest CT scans. Ten of the diagnosed cases were treated with oral praziquantel. Three of these patients were given carbamazepine from the beginning of parasiticidal treatment to prevent seizures; 4 of the remaining 7 patients experienced epileptic seizures during the treatment process. Four patients needed surgery to remove the lesions, and these individuals received praziquantel treatment right after the surgery.

RESULTS

Pathological examinations demonstrated eosinophilic granuloma in these patients. There was no disease recurrence or epilepsy in 11-40 months of follow-up; however, mild hemiplegia could still be observed in 2 cases after 12 months and 17 months of follow-up.

CONCLUSIONS

The possibility of cerebral paragonimiasis should be considered when ICH is detected in young patients who are either from an endemic area or have recently visited such an area; the relatively small amount of hemorrhage in cerebral paragonimiasis is often represented as small lesions surrounded by disproportionately larger edema on the imaging study. Preventive antiepileptic drugs should be used along with the administration of parasiticide.

Seizures and epilepsy in patients with a posterior circulation infarct

Seizures occur mainly in patients with cortical infarcts in the anterior circulation. Those related to a posterior circulation infarct (POCI) are considered rare. This study investigated the characteristics of patients with seizures related to a POCI. A total of 180 consecutive patients admitted with a POCI had a 2- to 7-year follow-up; 24 of them (13.6%) developed seizures. Vascular risk factors, etiology and extension of the infarct, degree of neurologic impairment, and outcome were compared in the patients with and without seizures. Complex partial type seizure was the most common presentation. Stroke characteristics were largely the same in the patients with and without seizures. History of a previous stroke was noted in 62.5% of the seizure group and in 17.9% of the nonseizure group (P < .001). Clinical outcome was worse in the seizure group (P = .004). The relative incidence of seizures in patients with a POCI was not lower than that in the overall stroke population. The high incidence of recurrent stroke is the main risk factor for seizures in patients with a POCI. The seizures themselves are responsible for the increased dependence rate.

Predictors and outcome of seizures after spontaneous intracerebral hemorrhage. Clinical article

OBJECT

Seizures are an important neurological complication of spontaneous intracerebral hemorrhage (ICH). A better understanding of the risk factors of seizures following ICH is needed to predict which patients will require treatment.

METHODS

Two hundred and forty-three adult patients were enrolled in this 1-year retrospective study. Multiple logistic regression was used to evaluate the relationship between baseline clinical factors and the presence or absence of seizure during the study period.

RESULTS

Seizures occurred in 20 patients with ICH, including acute symptomatic seizures in 9 and unprovoked seizures in 11. None progressed to status epilepticus during hospitalization. After a minimum 3-year follow-up period, the mean Glasgow Outcome Scale score was 3.8+/-1.1 for patients who had had seizures and 3.5+/-1.3 for those who had not. The multiple logistic regression model demonstrated that the mean ICH volume was independently associated with seizures, and any increase of 1 mm3 in ICH volume increased the seizure rate by 2.7%.

CONCLUSIONS

Higher mean ICH volumes at presentation were predictive of seizure, and the presence of late seizures was predictive of developing epilepsy. Most seizures occurred within 2 years of spontaneous ICH over a minimum of 3 years of follow-up.

[Seizures and epilepsies after stroke]

Epilepsies after stroke represent 20% of all adult-onset epilepsies and exhibit special characteristics with respect to diagnosis, treatment, and prognosis. Patients are frequently amnestic for their seizures the signs of which can be very subtle. Postictal pareses and confusional states can last for days, which further complicate diagnosis. Single seizures after stroke were reported in 2% to 10% of cases, and community-based studies found epilepsies in 3% to 4% of stroke patients. Analyses of subgroups identified epilepsy risks of 3% after ischemic infarction, 6% to 10% after intracerebral hemorrhage, and 9% after subarachnoid hemorrhage. Status epilepticus developed in less than 1% of stroke patients. Besides etiology, further risk factors for epilepsy comprise: remote seizures (latency >2 weeks, risk of recurrence >50%) more than early seizures (latency <2 weeks, risk of recurrence <50%), extent of stroke, cortical involvement, and degree of neurological deficit. The first appearance of seizures in patients older than 60 years represents a risk factor for future stroke with a hazard ratio of 2.89.There is currently no sufficient evidence for starting AED treatment before seizures occur. The benefit is still unclear of starting AED after a single early post-stroke seizure. Most authors recommend AED treatment after the second seizure but also after a first remote seizure because of the high risk of seizure recurrence in these situations. Possible pharmacokinetic interactions should be considered when choosing AED. Especially the first-generation AED carry the potential to interact with comedication, which is usually seen in stroke patients receiving substances such warfarin and salicylates. Only very few studies investigate specific AED exclusively in stroke patients. Lamotrigine and gabapentin have been successfully tested in these patients.

Neuropsychological features of lesion-related epilepsy in adults: an overview

Lesional epilepsy is thought to be a direct consequence of focal brain lesions of dysgenetic, neoplastic, vascular, or traumatic origin. It has been estimated that at least half of all epilepsies are the result of such lesions. The current discussion includes an overview of the cognitive and behavioral presentations in adults with epilepsy secondary to focal pathology. The neuropsychological presentation in this population is influenced by many factors, including the location and nature of the underlying lesion, seizure characteristics, the effects of treatment, and patient variables. Few studies attempt to disentangle the specific contributions of these variables to cognitive performance. However, where available studies examining the separable effects of seizure-related variables on cognitive functioning in individuals with lesional epilepsy are also reviewed. This overview includes a discussion of focal malformations of cortical and vascular development and select foreign tissue and acquired lesions.