Review of the Utility of Prophylactic Anticonvulsant Use in Critically Ill Patients With Intracerebral Hemorrhage

Guidelines for Seizure Prophylaxis in Patients Hospitalized with Nontraumatic Intracerebral Hemorrhage: A Clinical Practice Guideline for Health Care Professionals from the Neurocritical Care Society

BACKGROUND

There is practice heterogeneity in the use, type, and duration of prophylactic antiseizure medications (ASM) in patients hospitalized with acute nontraumatic intracerebral hemorrhage (ICH).

METHODS

We conducted a systematic review and meta-analysis assessing ASM primary prophylaxis in adults hospitalized with acute nontraumatic ICH. The following population, intervention, comparison, and outcome (PICO) questions were assessed: (1) Should ASM versus no ASM be used in patients with acute ICH with no history of clinical or electrographic seizures? (2) If an ASM is used, should levetiracetam (LEV) or phenytoin/fosphenytoin (PHT/fPHT) be preferentially used? and (3) If an ASM is used, should a long (> 7 days) versus short (≤ 7 days) duration of prophylaxis be used? The main outcomes assessed were early seizure (≤ 14 days), late seizures (> 14 days), adverse events, mortality, and functional and cognitive outcomes. We used Grading of Recommendations Assessment, Development, and Evaluation methodology to generate recommendations.

RESULTS

The initial literature search yielded 1,988 articles, and 15 formed the basis of the recommendations. PICO 1: although there was no significant impact of ASM on the outcomes of early or late seizure or mortality, meta-analyses demonstrated increased adverse events and higher relative risk of poor functional outcomes at 90 days with prophylactic ASM use. PICO 2: we did not detect any significant positive or negative effect of PHT/fPHT compared to LEV for early seizures or adverse events, although point estimates tended to favor LEV. PICO 3: based on one decision analysis, quality-adjusted life-years were increased with a shorter duration of ASM prophylaxis.

CONCLUSIONS

We suggest avoidance of prophylactic ASM in hospitalized adult patients with acute nontraumatic ICH (weak recommendation, very low quality of evidence). If used, we suggest LEV over PHT/fPHT (weak recommendation, very low quality of evidence) for a short duration (≤ 7 days; weak recommendation, very low quality of evidence).

Modified CAVE score for predicting late seizures after intracerebral hemorrhage

BACKGROUND AND PURPOSE

Seizures commonly occur in patients with intracerebral hemorrhage (ICH). Anticonvulsants are commonly used for preventing seizures in patients with ICH. Thus, patients with ICH at high risk of seizures must be identified. The study aims to elucidate whether double the score of cortex involvement in ICH patients can increase accuracy of CAVE score for predicting late seizures.

METHOD

This retrospective analysis of the medical records of surviving patients admitted between June 1, 2013, and December 31, 2019. Validated the CAVE score and modified it (CAVE2). The main outcome of patients with ICH was seizures. The first seizures occurring within 7 days after a stroke were defined as early seizures. Seizures occurring after 1 week of stroke onset, including patients who had experienced early seizures or patients who had not, were defined as late seizures. CAVE and CAVE2 scores were validated using the cohort. The accuracy and discrimination of those two scores were accessed by the area under the operating characteristic curve. Akaike information criterion, integrated discrimination improvement, and continuous net reclassification improvement were used to assess the performance of the CAVE and CAVE2 scores.

RESULTS

In the cohort showed that late seizures occurred in 12.7% (52/408) of patients with ICH. Male sex, age > 65 years, cortex involvement, and early seizures were associated with the occurrence of late seizures, with odds ratios of 2.09, 2.04, 4.12, and 3.78, respectively. The risk rate of late seizures was 6.66% (17/255), 14.8% (17/115), and 47.4% (18/38) for CAVE scores ≤ 1, 2, and ≥ 3, and 4.6% (12/258), 18.3% (13/71), and 54.4 (20/37) for CAVE2 scores ≤ 1, 2, and ≥ 3 respectively. The C-statistics for the CAVE and CAVE2 scores were 0.73 and 0.74 respectively.

CONCLUSION

The CAVE score can identify patients with ICH and high risk for late seizures. The CAVE can be modified by changing the score of cortex involvement to 2 points to improve accuracy in predicting late seizures in patients with ICH.

Prophylactic antiseizure drugs for spontaneous intracerebral hemorrhage: An updated systematic review and meta-analysis

BACKGROUND

There is concern that recommendations on prophylactic antiseizure drugs (PASDs) for patients with spontaneous intracerebral hemorrhage (sICH) are biased by studies using older drugs and no electrographic monitoring.

AIMS

We performed a systematic review and meta-analysis to determine whether PASDs in patients with sICH reduced seizure occurrence and improved functional outcomes. We included analyses of newer trials, newer antiseizure drugs, and effectiveness in patients with consistent electrographic monitoring.

METHODS

Medline, Embase, and Cochrane were searched from inception until 12 August 2022, to identify studies with patients with sICH treated with PASDs, regardless of study design. The studied outcomes were functional status and occurrence of seizures.

RESULTS

Fourteen studies were included, including 6742 patients. Risk of bias was low overall. There was no effect of PASD on seizure occurrence overall (odds ratio (OR) 0.73, 95% confidence interval (CI) 0.47-1.15), but they were associated with reduced occurrence in studies with electrographic monitoring (OR 0.36, 95% CI 0.18-0.70). There was no effect of PASDs on functional outcomes (OR 1.15; 95% CI 0.91-1.47) or mortality (OR 0.85, 95% CI 0.65-1.11).

CONCLUSION

Prophylactic antiseizure medications after sICH reduce seizures in studies with electroencephalogram monitoring in high-risk patients. However, this benefit did not reflect in the improvement of functional outcomes, even in studies with newer, less toxic, antiseizure drugs.

Be a PEACH and Hand Me That Levetiracetam: Seizure Prophylaxis for Spontaneous Intracerebral Hemorrhage

Safety and Efficacy of Prophylactic Levetiracetam for Prevention of Epileptic Seizures in the Acute Phase of Intracerebral Haemorrhage (PEACH): A Randomised, Double-Blind, Placebo-Controlled, Phase 3 Trial Peter-Derex L, Philippeau F, Garnier P, André-Obadia N, Boulogne S, Catenoix H, Convers P, Mazzola L, Gouttard M, Esteban M, Fontaine J, Mechtouff L, Ong E, Cho T-H, Nighoghossian N, Perreton N, Termoz A, Haesebaert J, Schott A-M, Rabilloud M, Pivot C, Dhelens C, Filip A, Berthezène Y, Rheims S, Boutitie F, Derex L. Lancet Neurol . 2022;21(9):781-791. doi:10.1016/S1474-4422(22)00235-6 Background: The incidence of early seizures (occurring within 7 days of stroke onset) after intracerebral haemorrhage reaches 30% when subclinical seizures are diagnosed by continuous EEG. Early seizures might be associated with haematoma expansion and worse neurological outcomes. Current guidelines do not recommend prophylactic antiseizure treatment in this setting. We aimed to assess whether prophylactic levetiracetam would reduce the risk of acute seizures in patients with intracerebral haemorrhage. Methods: The double-blind, randomised, placebo-controlled, phase 3 PEACH trial was conducted at three stroke units in France. Patients (aged 18 years or older) who presented with a non-traumatic intracerebral haemorrhage within 24 h after onset were randomly assigned (1:1) to levetiracetam (intravenous 500 mg every 12 h) or matching placebo. Randomisation was done with a web-based system and stratified by centre and National Institutes of Health Stroke Scale (NIHSS) score at baseline. Treatment was continued for 6 weeks. Continuous EEG was started within 24 h after inclusion and recorded over 48 h. The primary endpoint was the occurrence of at least one clinical seizure within 72 h of inclusion or at least one electrographic seizure recorded on continuous EEG, analysed in the modified intention-to-treat population, which comprised all patients who were randomly assigned to treatment and who had a continuous EEG performed. This trial was registered at ClinicalTrials.gov , NCT02631759, and is now closed. Recruitment was prematurely stopped after 48% of the recruitment target was reached due to a low recruitment rate and cessation of funding. Findings Between June 1, 2017, and April 14, 2020, 50 patients with mild-to-moderate severity intracerebral haemorrhage were included: 24 were assigned to levetiracetam and 26 to placebo. During the first 72 h, a clinical or electrographic seizure was observed in three (16%) of 19 patients in the levetiracetam group versus ten (43%) of 23 patients in the placebo group (odds ratio 0.16, 95% CI 0.03–0.94, p = 0.043). All seizures in the first 72 h were electrographic seizures only. No difference in depression or anxiety reporting was observed between the groups at 1 month or 3 months. Depression was recorded in three (13%) patients who received levetiracetam versus four (15%) patients who received placebo, and anxiety was reported for two (8%) patients versus one (4%) patient. The most common treatment-emergent adverse events in the levetiracetam group versus the placebo group were headache (nine [39%] vs six [24%]), pain (three [13%] vs ten [40%]), and falls (seven [30%] vs four [16%]). The most frequent serious adverse events were neurological deterioration due to the intracerebral haemorrhage (one [4%] vs four [16%]) and severe pneumonia (two [9%] vs two [8%]). No treatment-related death was reported in either group. Interpretation: Levetiracetam might be effective in preventing acute seizures in intracerebral haemorrhage. Larger studies are needed to determine whether seizure prophylaxis improves functional outcome in patients with intracerebral haemorrhage.

Acute Spontaneous Lobar Cerebral Hemorrhages Present a Different Clinical Profile and a More Severe Early Prognosis than Deep Subcortical Intracerebral Hemorrhages-A Hospital-Based Stroke Registry Study

Acute spontaneous intracerebral hemorrhage (ICH) is the most severe stroke subtype, with a high risk of death, dependence, and dementia. Knowledge about the clinical profile and early outcomes of ICH patients with lobar versus deep subcortical brain topography remains limited. In this study, we investigated the effects of ICH topography on demographics, cerebrovascular risk factors, clinical characteristics, and early outcomes in a sample of 298 consecutive acute ICH patients (165 with lobar and 133 with subcortical hemorrhagic stroke) available in a single-center-based stroke registry over 24 years. The multiple logistic regression analysis shows that variables independently associated with lobar ICH were early seizures (OR 6.81, CI 95% 1.27−5.15), chronic liver disease (OR 4.55, 95% CI 1.03−20.15), hemianopia (OR 2.55, 95% CI 1.26−5.15), headaches (OR 1.90, 95% CI 1.90, 95% IC 1.06−3.41), alcohol abuse (>80 gr/day) (OR 0−10, 95% CI 0.02−0,53), hypertension (OR 0,41, 95% CI 0.23−0−70), sensory deficit (OR 0.43, 95% CI 0.25−0.75), and limb weakness (OR: 0.47, 95% CI 0.24−0.93). The in-hospital mortality was 26.7% for lobar and 16.5% for subcortical ICH. The study confirmed that the clinical spectrum, prognosis, and early mortality of patients with ICH depend on the site of bleeding, with a more severe early prognosis in lobar intracerebral hemorrhage.

Effects of subarachnoid extension following intracerebral hemorrhage: A systematic review and meta-analysis

BACKGROUND

The effects of subarachnoid extension (SAHE) following intracerebral hemorrhage (ICH) have not yet been fully understood. We conducted a systematic review and meta-analysis of published literature on this topic to better understand the effects of SAHE.

METHODS

PubMed, Embase, and Cochrane databases were thoroughly searched from inception to October 16, 2022 to identify studies that evaluated the association between SAHE and mortality and worse functional outcomes in primary ICH. Crude odds ratios (cOR) and adjusted odds ratios (aOR) with 95% confidence interval (CI) were calculated to compare the endpoints.

RESULTS

Three studies with 3368 participants were eventually included in the analysis. In the short-term follow-up of the primary endpoint, no association was observed between SAHE and mortality (cOR: 0.51, 95% CI: 0.01-28.19; aOR: 2.31, 95% CI: 0.72-7.45). In the long-term follow-up of the primary endpoint, SAHE was associated with a significantly increased mortality of patients with primary ICH (cOR: 3.00, 95% CI: 2.27-3.98); however, only 1 study provided the values of aOR and 95% CI and showed that SAHE was not associated with increased mortality (aOR: 1.14, 95% CI: 0.71-1.83). For the secondary endpoint, the data of only 1 study on major disability (modified Rankin Scale = 3-5) were available, and the results revealed that SAHE increased the probability of major disability, but not after adjusting for baseline hematoma volume.

CONCLUSION

There is insufficient evidence to demonstrate the correlation between SAHE and mortality and worse functional outcomes in primary ICH. The validation of this correlation requires further studies as the potential effect and mechanisms of SAHE remain unclear.

Impact of seizures and their prophylaxis with antiepileptic drugs on rehabilitation course of patients with traumatic or hemorrhagic brain injury

OBJECTIVE

To determine whether, in patients undergoing rehabilitation after traumatic or hemorrhagic brain injury, seizures and the use of antiepileptic drugs (AEDs) negatively impact on functional outcome, and, in turn, whether prophylactic AED therapy can prevent the development of seizures.

DESIGN

Observational retrospective study.

SETTING

Highly specialized inpatient neurorehabilitation clinic.

PARTICIPANTS

Patients with traumatic brain injury (TBI), or hemorrhagic stroke (HS) consecutively admitted to our neurorehabilitation unit between January 1, 2009, and December 31, 2018.

MAIN MEASURES AND VARIABLES

Patients' demographic data, neurological status (Glasgow Coma Scale), and rehabilitation outcome (Functional Independence Measure scale), both assessed on admission and on discharge, associated neurosurgical procedures (craniectomy, or cranioplasty), AED use, early or late seizures occurrence, and death during hospitalization.

RESULTS

Of 740 patients, 162 (21.9%) had seizures, and prophylactic AEDs were started in 192 (25.9%). Multivariate logistic regression identified severity of brain injury as a risk factor for acute symptomatic seizures (ASS) in HS (OR = 1.800, 95%CI = 1.133-1.859, p = 0.013), and for unprovoked seizures (US) in TBI (OR = 1.679, 95%CI = 1.062-2.655, p = 0.027). Prophylaxis with AEDs reduced ASS frequency, but, if protracted for months, was associated with US occurrence (HS, p < 0.0001; TBI, p = 0.0002; vs. untreated patients). Presence of US (β = -0.12; p < 0.0001) and prophylaxis with AEDs (β = -0.09; p = 0.002), were associated with poor functional outcome, regardless of age, severity of brain insult, and HS vs. TBI subtype.

CONCLUSIONS

Severity of brain injury and occurrence of seizures during neurorehabilitation are the main driver of poor outcome in both HS and TBI. The possible detrimental role on the epileptogenic and functional outcome played by seizures prophylaxis with AEDs, nonetheless useful to prevent ASS if administered over the first week after the brain injury, warrants further investigation.

Closing the Gap in Pediatric Hemorrhagic Stroke: A Systematic Review

Pediatric hemorrhagic stroke (HS) accounts for a large proportion of childhood strokes, 1 of the top 10 causes of pediatric deaths. Morbidity and mortality lead to significant socio-economic and psychosocial burdens. To understand published data on recognizing and managing children with HS, we conducted a systematic review of the literature presented here. We searched PubMed, Embase, CINAHL and the Cochrane Library databases limited to English language and included 174 studies, most conducted in the USA (52%). Terminology used interchangeably for HS included intraparenchymal/intracranial hemorrhage, spontaneous ICH, and cerebrovascular accident (CVA). Key assessments informing prognosis and management included clinical scoring (Glasgow coma scale), and neuroimaging. HS etiologies reported were systemic coagulopathy (genetic, acquired pathologic, or iatrogenic), or focal cerebrovascular lesions (brain arteriovenous malformations, cavernous malformations, aneurysms, or tumor vascularity). Several scales were used to measure outcome: Glasgow outcome score (GOS), Kings outcome score for head injury (KOSCHI), modified Rankin scale (mRS) and pediatric stroke outcome measure (PSOM). Most studies described treatments of at-risk lesions. Few studies described neurocritical care management including raised ICP, seizures, vasospasm, or blood pressure. Predictors of poor outcome included ethnicity, comorbidity, location of bleed, and hematoma &gt;2% of total brain volume. Motor and cognitive outcomes followed independent patterns. Few studies reported on cognitive outcomes, rehabilitation, and transition of care models. Interdisciplinary approach to managing HS is urgently needed, informed by larger cohort studies targeting key clinical question (eg development of a field-guide for the clinician managing patients with HS that is reproducible internationally).

Safety and efficacy of prophylactic levetiracetam for prevention of epileptic seizures in the acute phase of intracerebral haemorrhage (PEACH): a randomised, double-blind, placebo-controlled, phase 3 trial

BACKGROUND

The incidence of early seizures (occurring within 7 days of stroke onset) after intracerebral haemorrhage reaches 30% when subclinical seizures are diagnosed by continuous EEG. Early seizures might be associated with haematoma expansion and worse neurological outcomes. Current guidelines do not recommend prophylactic antiseizure treatment in this setting. We aimed to assess whether prophylactic levetiracetam would reduce the risk of acute seizures in patients with intracerebral haemorrhage.

METHODS

The double-blind, randomised, placebo-controlled, phase 3 PEACH trial was conducted at three stroke units in France. Patients (aged 18 years or older) who presented with a non-traumatic intracerebral haemorrhage within 24 h after onset were randomly assigned (1:1) to levetiracetam (intravenous 500 mg every 12 h) or matching placebo. Randomisation was done with a web-based system and stratified by centre and National Institutes of Health Stroke Scale (NIHSS) score at baseline. Treatment was continued for 6 weeks. Continuous EEG was started within 24 h after inclusion and recorded over 48 h. The primary endpoint was the occurrence of at least one clinical seizure within 72 h of inclusion or at least one electrographic seizure recorded on continuous EEG, analysed in the modified intention-to-treat population, which comprised all patients who were randomly assigned to treatment and who had a continuous EEG performed. This trial was registered at ClinicalTrials.gov, NCT02631759, and is now closed. Recruitment was prematurely stopped after 48% of the recruitment target was reached due to a low recruitment rate and cessation of funding.

FINDINGS

Between June 1, 2017, and April 14, 2020, 50 patients with mild-to-moderate severity intracerebral haemorrhage were included: 24 were assigned to levetiracetam and 26 to placebo. During the first 72 h, a clinical or electrographic seizure was observed in three (16%) of 19 patients in the levetiracetam group versus ten (43%) of 23 patients in the placebo group (odds ratio 0·16, 95% CI 0·03-0·94, p=0·043). All seizures in the first 72 h were electrographic seizures only. No difference in depression or anxiety reporting was observed between the groups at 1 month or 3 months. Depression was recorded in three (13%) patients who received levetiracetam versus four (15%) patients who received placebo, and anxiety was reported for two (8%) patients versus one (4%) patient. The most common treatment-emergent adverse events in the levetiracetam group versus the placebo group were headache (nine [39%] vs six [24%]), pain (three [13%] vs ten [40%]), and falls (seven [30%] vs four [16%]). The most frequent serious adverse events were neurological deterioration due to the intracerebral haemorrhage (one [4%] vs four [16%]) and severe pneumonia (two [9%] vs two [8%]). No treatment-related death was reported in either group.

INTERPRETATION

Levetiracetam might be effective in preventing acute seizures in intracerebral haemorrhage. Larger studies are needed to determine whether seizure prophylaxis improves functional outcome in patients with intracerebral haemorrhage.

FUNDING

French Ministry of Health.

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.

Management of Intracerebral Hemorrhage: Update and Future Therapies

PURPOSE OF REVIEW

Intracerebral hemorrhage (ICH) represents about 15% of all strokes in the USA, but almost 50% of fatal strokes. There are many causes of ICH, but the most common are hypertension and cerebral amyloid angiopathy. This review will discuss new advances in the treatment of intracerebral hemorrhage.

RECENT FINDINGS

The treatment of ICH focuses on management of edema, aggressive blood pressure reduction, and correction of coagulopathy. Early initiation of supportive medical therapies, including blood pressure management, in a neurological intensive care unit reduces mortality, but at present there is no definitive, curative therapy analogous to mechanical thrombectomy for ischemic stroke. Nonetheless, new medical and surgical approaches promise more successful management of ICH patients, especially new approaches to surgical management. In this review, we focus on the current standard of care of acute ICH and discuss emerging therapies that may alter the landscape of this devastating disease.

Neurologic Complications in the Postoperative Neurosurgery Patient

PURPOSE OF REVIEW

This article discusses neurologic complications encountered in the postoperative care of neurosurgical patients that are common or key to recognize in the immediate postoperative period. The major neurosurgical subspecialty procedures (cerebrovascular neurosurgery, neuro-oncology, epilepsy neurosurgery, functional neurosurgery, CSF diversion, endovascular neurosurgery, and spinal surgery) are broadly included under craniotomy procedures, endovascular/vascular procedures, and spinal procedures. This article focuses on the range of complications inherent in these approaches with specific scenarios addressed as applicable.

RECENT FINDINGS

The morbidity and mortality related to neurosurgical procedures remains high, necessitating ongoing research and quality improvement efforts in perioperative screening, intraoperative management, surgical approaches, and postoperative care of these patients. Emerging research continues to investigate safer and newer options for routine neurosurgical approaches, such as coiling over clipping for amenable aneurysms, endoscopic techniques for transsphenoidal hypophysectomy, and minimally invasive spinal procedures; postoperative monitoring and care of patients after these procedures continues to be a key component in the continuum of care for improving outcomes.

SUMMARY

Postoperative care of patients undergoing major neurosurgical procedures is an integral part of many neurocritical care practices. Neurosurgeons often enlist help from neurologists to assist with evaluation, interpretation, and management of complications in routine inpatient settings. Awareness of the common neurologic complications of various neurosurgical procedures can help guide appropriate clinical monitoring algorithms and quality improvement processes for timely evaluation and management of these patients.

Seizure Prophylaxis After Spontaneous Intracerebral Hemorrhage

Importance

Limited evidence is available concerning optimal seizure prophylaxis after spontaneous intracerebral hemorrhage (sICH).

Objective

To evaluate which of 4 seizure prophylaxis strategies provides the greatest net benefit for patients with sICH.

Design, Setting, and Participants

This decision analysis used models to simulate the following 4 common scenarios: (1) a 60-year-old man with low risk of early (≤7 days after stroke) (10%) and late (3.6% or 9.8%) seizures and average risk of short- (9%) and long-term (30%) adverse drug reaction (ADR); (2) an 80-year-old woman with low risk of early (10%) and late (3.6% or 9.8%) seizures and high short- (24%) and long-term (80%) ADR risks; (3) a 55-year-old man with high risk of early (19%) and late (34.8% or 46.2%) seizures and low short- (9%) and long-term (30%) ADR risks; and (4) a 45-year-old woman with high risk of early (19%) and late (34.8% or 46.2%) seizures and high short- (18%) and long-term (60%) ADR risks.

Interventions

The following 4 antiseizure drug strategies were included: (1) conservative, consisting of short-term (7-day) secondary early-seizure prophylaxis with long-term therapy after late seizure; (2) moderate, consisting of long-term secondary early-seizure prophylaxis or late-seizure therapy; (3) aggressive, consisting of long-term primary prophylaxis; and (4) risk guided, consisting of short-term secondary early-seizure prophylaxis among low-risk patients (2HELPS2B score, 0), short-term primary prophylaxis among patients at higher risk (2HELPS2B score, ≥1), and long-term secondary therapy for late seizure.

Main Outcomes and Measures

Quality-adjusted life-years (QALYs).

Results

For scenario 1, the risk-guided strategy (8.13 QALYs) was preferred over the conservative (8.08 QALYs), moderate (8.07 QALYs), and aggressive (7.88 QALYs) strategies. For scenario 2, the conservative strategy (2.18 QALYs) was preferred over the risk-guided (2.17 QALYs), moderate (2.09 QALYs), and aggressive (1.15 QALYs) strategies. For scenario 3, the aggressive strategy (9.21 QALYs) was preferred over the risk-guided (8.98 QALYs), moderate (8.93 QALYs), and conservative (8.77 QALYs) strategies. For scenario 4, the risk-guided strategy (11.53 QALYs) was preferred over the conservative (11.23 QALYs), moderate (10.93 QALYs), and aggressive (8.08 QALYs) strategies. Sensitivity analyses suggested that short-term strategies (conservative and risk guided) are preferred under most scenarios, and the risk-guided strategy performs comparably to or better than alternative strategies in most settings.

Conclusions and Relevance

This decision analytical model suggests that short-term (7-day) prophylaxis dominates longer-term therapy after sICH. Use of the 2HELPS2B score to guide clinical decisions for initiation of short-term primary vs secondary early-seizure prophylaxis should be considered for all patients after sICH.

A Systematic Review and Meta-Analysis of Antiepileptic Prophylaxis in Spontaneous Intracerebral Hemorrhage

BACKGROUND

Frequency of clinical seizures may be as high as 16% in patients with spontaneous intracerebral hemorrhage (ICH). Current guidelines recommend against antiepileptic drug (AED) prophylaxis, but this recommendation is based on older trials, and the effect of newer AEDs is uncertain. The aim of this review was to study effects of AEDs on seizure occurrence and outcome in patients with spontaneous ICH.

METHODS

We searched key databases using combinations of the following terms: "levetiracetam," "prophylaxis," "ICH," "intracerebral hemorrhage," "intraparenchymal hemorrhage." Selected studies were reviewed for level of evidence and overall quality of data using Grading of Recommendations, Assessment, Development and Evaluations criteria. A meta-analysis was performed to evaluate seizure prevention, functional outcome, and mortality in patients with seizure prophylaxis compared with no prophylaxis following spontaneous ICH.

RESULTS

Seven articles met inclusion criteria and were graded level III studies. Administration of AEDs was not associated with reduced seizure risk (odds ratio 1.14, 95% confidence interval 0.47-2.77, P = 0.77). There was an association between AED prophylaxis and poor functional outcome (odds ratio 1.65, 95% confidence interval 1.17-2.31, P = 0.004) but not mortality (odds ratio 1.04, 95% confidence interval 0.62-1.72, P = 0.89). The overall quality of evidence using Grading of Recommendations, Assessment, Development and Evaluations criteria was low.

CONCLUSIONS

This systematic review and meta-analysis including recent studies focusing on newer AEDs supports the 2015 guidelines regarding AED use in spontaneous ICH. There are some important caveats, including a possible confounding association between AED use and higher ICH score and the overall poor quality of the available data. A randomized clinical trial may be helpful.

Seizures and epilepsy after intracerebral hemorrhage: an update

Seizures are common after intracerebral hemorrhage, occurring in 6-15% of the patients, mostly in the first 72 h. Their incidence reaches 30% when subclinical or non-convulsive seizures are diagnosed by continuous electroencephalogram. Several risk factors for seizures have been described including cortical location of intracerebral hemorrhage, presence of intraventricular hemorrhage, total hemorrhage volume, and history of alcohol abuse. Seizures after intracerebral hemorrhage may theoretically be harmful as they can lead to sudden blood pressure fluctuations, increased intracranial pressure, and neuronal injury due to increased metabolic demand. Some recent studies suggest that acute symptomatic seizures (occurring within 7 days of stroke) are associated with worse functional outcome and increased risk of death despite accounting for other known prognostic factors such as age and baseline hemorrhage volume. However, the impact of seizures on prognosis is still debated and it remains unclear if treating or preventing seizures might lead to improved clinical outcome. Thus, the currently available scientific evidence does not support the routine use of antiseizure medication as primary prevention among patients with intracerebral hemorrhage. Only prospective adequately powered randomized-controlled trials will be able to answer whether seizure prophylaxis in the acute or longer term settings is beneficial or not in patients with intracerebral hemorrhage.

Management of Intracerebral Hemorrhage: JACC Focus Seminar

Intracerebral hemorrhage (ICH) accounts for a disproportionate amount of stroke-related morbidity and mortality. Although chronic hypertension and cerebral amyloid angiopathy are the underlying cerebral vasculopathies accounting for the majority of ICH, there are a broad range of potential causes, and effective management requires accurate identification and treatment of the underlying mechanism of hemorrhage. Magnetic resonance imaging and vascular imaging techniques play a critical role in identifying disease mechanisms. Modern treatment of ICH focuses on rapid stabilization, often requiring urgent treatment of mass effect, aggressive blood pressure reduction and correction of contributing coagulopathies to achieve hemostasis. We discuss management of patients with ICH who continue to require long-term anticoagulation, the interaction of ICH with neurodegenerative diseases, and our approach to prognostication after ICH. We close this review with a discussion of novel medical and surgical approaches to ICH treatment that are being tested in clinical trials.

Antiepileptic Drugs to Prevent Seizures After Spontaneous Intracerebral Hemorrhage

Background and Purpose- We sought to evaluate the available literature to determine whether primary seizure prevention with antiepileptic drugs reduces the risk of poor outcomes and clinically relevant seizures among adult patients with spontaneous intracerebral hemorrhage. Methods- Meta-analysis of observational studies and randomized controlled trials evaluating the use of any antiepileptic drug for primary seizure prevention among adult (≥18 years) patients with spontaneous intracerebral hemorrhage. The primary end point was poor clinical outcome at the longest recorded follow-up, defined as either a high (>3) modified Rankin Scale score or all-cause mortality during follow-up if the modified Rankin Scale score was not recorded. Early and late seizures were secondary outcomes. A random mixed effects model was used to estimate the pooled odds ratio of outcomes and associated 95% CI. Results- We identified 7 studies with a total of 3241 patients for analysis of the primary outcome and 4 studies with a total of 1861 patients for analysis of the secondary outcomes. Overall, the use of antiepileptic drugs was not associated with a high Rankin Scale or all-cause mortality (odds ratio: 0.99; 95% CI, 0.66-1.49) or incident seizures (odds ratio: 0.89; 95% CI, 0.52-1.51) at the longest recorded follow-up time. Conclusions- The use of antiepileptic drugs as primary prevention among adult patients with spontaneous intracerebral hemorrhage is not associated with improved neurological function during long-term follow-up. Future studies should focus on the preventive use of distinct antiepileptic agents among patients at high risk of both seizures and poor outcomes.

An update on neurocritical care for intracerebral hemorrhage

Introduction: Intracerebral hemorrhage remains one of the leading causes of death and disability worldwide with few established interventions that improve neurologic outcome. Research dedicated to better understanding and treating hemorrhagic strokes has multiplied in the past decade. Areas Covered: This review aims to discuss the current landscape of management of intracerebral hemorrhage in a critical care setting and provide updates regarding developments in therapeutic interventions and targets. PubMed was utilized to review recent literature, with a focus on large trials and meta-analyses, which have shaped current practice. Published committee guidelines were also included. A focus was placed on research published after 2015 in an effort to supplement previous reviews included in this publication. Expert Opinion: Literature pertaining to ICH management has allowed for a greater understanding of ineffective strategies as opposed to those of benefit. Despite this, mortality has improved worldwide, which may be the result of growing research efforts. Areas of future research that will impact mortality and improve neurologic outcomes include prevention of hematoma expansion, optimization of blood pressure targets, effective coagulopathy reversal, and minimally invasive surgical techniques to reduce hematoma burden.

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).

Prescription patterns for routine EEG ordering in patients with intracranial hemorrhage admitted to a neurointensive care unit

PURPOSE

To examine clinical factors, including established electroencephalography (EEG) consensus recommendations, that may influence EEG-prescription in critically-ill intracerebral hemorrhage (ICH) patients in the neurointensive care unit.

METHODS

Retrospective analysis of 330 ICH patients admitted to a neurointensive care unit at an academic medical center between 01/2013-12/2015. We compared EEG prescription patterns with current EEG consensus recommendations, and employed univariate and multivariable logistic regression modeling to determine clinical variables associated with EEG ordering.

RESULTS

Seventy-eight (41%) of 190 subjects underwent EEG in accordance with EEG-consensus guidelines, demonstrating an overall accuracy (probability that EEG prescription aligned with EEG consensus recommendations) of 64.6% (95%-CI59.1-69.7). Factors independently associated with EEG ordering included fulfillment of EEG consensus recommendations, lower admission Glasgow Coma Scale (GCS), and presence of clinical seizures. The unadjusted and adjusted C-statistics for fulfillment of consensus recommendations was 0.74 (95%-CI 0.69-0.80) and 0.85 (95%-CI 0.81-0.90), respectively. Among 83 subjects undergoing EEG (25.2%), EEG findings informed clinical decision-making in 50 patients (60%).

CONCLUSIONS

EEG appeared underused in ICH, since <50% of patients who fulfilled guideline criteria underwent EEG. Prescription of EEG was related to factors beyond those included in consensus recommendations. Validation of our findings and their association with outcome is required.

Prophylactic Anticonvulsants in Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

Prophylactic anticonvulsants are routinely prescribed in the acute setting for intracerebral hemorrhage (ICH) patients, but some studies have reported an association with worse outcomes. We sought to characterize the prevalence and predictors of prophylactic anticonvulsant administration after ICH as well as guideline adherence. We also sought to determine whether prophylactic anticonvulsants were independently associated with poor outcome.

METHODS

We performed a retrospective study of primary ICH in our two academic centers. We used a propensity matching approach to make treated and non-treated groups comparable. We conducted multiple logistic regression analysis to identify independent predictors of prophylactic anticonvulsant initiation and its association with poor outcome as measured by modified Rankin score.

RESULTS

We identified 610 patients with primary ICH, of whom 98 were started on prophylactic anticonvulsants. Levetiracetam (97%) was most commonly prescribed. Age (OR 0.97, 95% CI 0.95-0.99, p < .001), lobar location (OR 2.94, 95% CI 1.76-4.91, p < .001), higher initial National Institutes of Health Stroke Scale (NIHSS) score (OR 2.31, 95% CI 1.40-3.79, p = .001), craniotomy (OR 3.06, 95% CI 1.51-6.20, p = .002), and prior ICH (OR 2.36, 95% CI 1.10-5.07, p = .028) were independently associated with prophylactic anticonvulsant initiation. Prophylactic anticonvulsant use was not associated with worse functional outcome [modified Rankin score (mRS) 4-6] at hospital discharge or with increased case-fatality. There was no difference in prescribing patterns after 2010 guideline publication.

DISCUSSION

Levetiracetam was routinely prescribed following ICH and was not associated with worse outcomes. Future investigations should examine the effect of prophylactic levetiracetam on cost and neuropsychological outcomes as well as the role of continuous EEG in identifying subclinical seizures.

Seizures, periodic and rhythmic patterns in primary intraventricular hemorrhage

Objective

Primary intraventricular hemorrhage (pIVH) uncommonly presents with seizures. There are no prior data regarding the frequency of seizures, periodic and rhythmic patterns on continuous electroencephalography (EEG), (cEEG) in these patients.

Methods

We retrospectively assessed frequency of seizures, periodic discharges, and rhythmic patterns in pIVH patients undergoing cEEG monitoring. We reviewed indications for cEEG, demographics, GCS at presentation and during cEEG, modified Graeb score (mGS), presence of hydrocephalus, cEEG duration, findings and use of antiseizure medications (ASM). cEEG patterns were classified according to location and morphology. All patterns were considered “hyperexcitable” except GRDA. The ictal‐interictal continuum (IIC) was defined as LRDA, PDs, and/or SW >1 Hz but <2.5 Hz, not meeting criteria for definite electrographic seizures.

Results

Eleven patients had pIVH with median age of 81 (46–87) years and median mGS of 15 (9–23). Hydrocephalus was present in 7 (63.6%) and all underwent external ventricular drain (EVD) placement. Median cEEG recording was 19 (12–156) hours. Periodic or rhythmic EEG patterns were seen in 7 of 11 (64%), 5 of which were “hyperexcitable”. For the 5 patients with pIVH, EVDs, and hyperexcitable patterns, 4 (80%) were lateralized contralateral to the EVD and 1 (20%) was generalized to the EVD. The only significant difference between the hyperexcitable and non‐hyperexcitable group was duration of cEEG monitoring (P = 0.007).

Interpretation

Hyperexcitable patterns were common in our cases. Further research is warranted to assess prevalence of hyperexcitable patterns, their risk factors, underlying pathophysiology, and association with neuronal injury in pIVH.

Electrographic and Clinical Natural History of Lateralized Periodic Discharges

PURPOSE

The long-term electrographic features of lateralized periodic discharges (LPD) and their impact on clinical management are unclear. The authors investigated routine EEGs (rEEG) to analyze the delayed natural history of LPDs, and studied the clinical care of these patients.

METHODS

After IRB approval, the prospectively maintained continuous EEG (cEEG) database was searched to identify patients fulfilling the following criteria: LPDs on cEEG, age ≥18 years, no epilepsy history, and rEEG completed within 1 to 12 months of hospital discharge. Their rEEGs were reviewed followed by clinical data extraction. Appropriate statistical tools were used for data analysis.

RESULTS

Thirty-nine patients (20 females) with a mean age of 63.3 ± 16.8 years at the time of cEEG fulfilled the study criteria. Thirty-three (85%) had associated electrographic seizures. rEEG was performed 4.7 ± 3.5 months after cEEG. Seven (18%) patients had interictal epileptiform discharges (IEDs) on the rEEG. The LPDs on cEEG of these patients were more often continuous, with an amplitude >2 times their background compared with 10 (26%) patients with normal rEEGs findings. After a mean follow-up of 19.8 ± 9.9 months, 11 (31%) patients developed epilepsy, but only 3 had IEDs on their rEEG. Majority (86%) of patients were on AEDs at the time of last follow-up.

CONCLUSIONS

LPDs lead to markers of epileptogenicity in around 18% of patients. One-third of the study population developed epilepsy. rEEG findings were not found to be good indicators of epilepsy development in our small, retrospective study limited by its sampling bias. Indiscriminate, long-term use of AEDs in these patients is a concerning finding.

Antiepileptic drugs in critically ill patients

BACKGROUND

The incidence of seizures in intensive care units ranges from 3.3% to 34%. It is therefore often necessary to initiate or continue anticonvulsant drugs in this setting. When a new anticonvulsant is initiated, drug factors, such as onset of action and side effects, and patient factors, such as age, renal, and hepatic function, should be taken into account. It is important to note that the altered physiology of critically ill patients as well as pharmacological and nonpharmacological interventions such as renal replacement therapy, extracorporeal membrane oxygenation, and target temperature management may lead to therapeutic failure or toxicity. This may be even more challenging with the availability of newer antiepileptics where the evidence for their use in critically ill patients is limited.

MAIN BODY

This article reviews the pharmacokinetics and pharmacodynamics of antiepileptics as well as application of these principles when dosing antiepileptics and monitoring serum levels in critically ill patients. The selection of the most appropriate anticonvulsant to treat seizure and status epileptics as well as the prophylactic use of these agents in this setting are also discussed. Drug-drug interactions and the effect of nonpharmacological interventions such as renal replacement therapy, plasma exchange, and extracorporeal membrane oxygenation on anticonvulsant removal are also included.

CONCLUSION

Optimal management of antiepileptic drugs in the intensive care unit is challenging given altered physiology, polypharmacy, and nonpharmacological interventions, and requires a multidisciplinary approach where appropriate and timely assessment, diagnosis, treatment, and monitoring plans are in place.

Prophylactic Anticonvulsants in Patients Undergoing Craniotomy: A Single-Center Experience

Background

There is no consensus on the efficacy of seizure prophylaxis in patients undergoing craniotomy. Some studies show that antiepileptic use decreases the risk of seizures, but other studies do not support this. The present study investigated the role of antiepileptic drugs in patient undergoing craniotomy due to various intracranial pathologies.

Material/Methods

A retrospective review was performed in adult patients undergoing craniotomy between January 2013 and June 2017. Results of 282 patients who did not have a history of seizures and had craniotomies for various reasons were included. In all patients with craniotomy planned, prophylactic AEDs were initiated pre-operatively.

Results

The incidence of postoperative seizures was 17.7% when all craniotomized patients were considered. The most commonly used anticonvulsant agent was phenytoin (75.2%). No serious antiepileptic drug reaction occurred requiring cessation of treatment.

Conclusions

Prophylactic antiepileptic treatment of patients undergoing craniotomy should not be continued beyond the first perioperative week if there is no serious brain injury. The intra- or extra-axial placement of the tumor affects the prophylaxis. Further randomized controlled studies are warranted in the future to investigate the efficacy of these medications.