Use of Anticonvulsant Prophylaxis for Cerebral Haemorrhage

Risk of Seizure

• The reported risk of seizures in patients with acute spontaneous ICH ranges from 4.2 to 29 percent. Seizures are more common in lobar as compared to deep hemorrhage.
• The frequency depends in part on the extent of monitoring, as seizures associated with ICH are often nonconvulsive
• If a seizure occurs, appropriate intravenous antiepileptic drug (AED) treatment should be administered to prevent recurrent seizures. The choice of the initial antiepileptic agent depends upon individual circumstances and contraindications. Current guidelines suggest the use of intravenous phenytoin in this setting¹
• Initiate fosphenytoin or other anticonvulsant definitely for seizure activity or lobar hemorrhage, and optionally in other patients. Levetiracetam has shown efficacy in children for prophylaxis of early posthemorrhagic seizures. Additional data suggest that levetiracetam is more effective than phenytoin for seizure prophylaxis without suppression of cognitive abilities in patients with ICH²

Prophylaxis prior to Seizure

• While some experts suggest a brief period of AED prophylaxis soon after ICH onset as a potential means of reducing the risk for early seizures in patients with lobar hemorrhages, 2010 guidelines recommend against prophylactic use of AEDs. This strategy has not been tested prospectively in clinical trials
• It was associated with poorer outcomes (a concern that has also been raised for subarachnoid hemorrhage patients), these were nonrandomized, observational studies, and sample size did not allow for examination of a differential effect from different AED
• The 2010 AHA/ASA guidelines do not offer recommendations on prophylactic anticonvulsants, but suggest that continuous EEG monitoring is probably indicated in patients with intracranial hemorrhage whose mental status is depressed out of proportion to the degree of brain injury
• Prophylactic anticonvulsant therapy has been recommended in patients with lobar hemorrhages to reduce the risk of early seizures. One large, single-center study showed that prophylactic antiepileptic drugs significantly reduced the number of clinical seizures in these patients
• In addition, AHA/ASA guidelines from 2012 suggest that prophylactic anticonvulsants may be considered for patients with aneurysmal subarachnoid hemorrhage. In such cases, however, anticonvulsant use should generally be limited to the immediate post-hemorrhagic period. Routine long-term use is not recommended, but it may be considered in patients with a prior seizure history, intracerebral hematoma, intractable hypertension, or infarction or aneurysm at the middle cerebral artery

References:

1. www.uptodate.com
2. Medscape http://emedicine.medscape.com/article/1916662-treatment#aw2aab6b6b2 
3. Seizure Prophylaxis in Patients with Traumatic Brain Injury. Department of Surgical Education, Orlando Regional Medical Center (2012)
4. The prophylactic use of an antiepileptic drug in intracerebral hemorrhage. Clin Neurol Neurosurg (2011), doi:10.1016/j.clineuro.2011.07.008