Anticonvulsant Prophylaxis for Hemorrhagic Stroke

• Early seizure activity occurs in 4-28% of patients with intracerebral hemorrhage; these seizures are often nonconvulsive

Treatment

• According to American Heart Association/American Stroke Association (AHA/ASA) 2010 guidelines for the management of spontaneous intracerebral hemorrhage, patients with clinical seizures or electroencephalographic (EEG) seizure activity accompanied by a change in mental status should be treated with antiepileptic drugs
• Patients for whom treatment is indicated should immediately receive a benzodiazepine, such as lorazepam or diazepam, for rapid seizure control.
• This should be accompanied by phenytoin or fosphenytoin loading for longer-term control

Prophylaxis

• Remains uncertain
• In prospective and population-based studies, clinical seizures have not been associated with worse neurologic outcome or mortality.
• 2 studies have reported worse outcomes in patients who did not have a documented seizure but who received antiepileptic drugs (primarily phenytoin)
• 2010 AHA/ASA guidelines do not offer recommendations on prophylactic anticonvulsants
• Suggest 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
• AHA/ASA guidelines from 2012 suggest that prophylactic anticonvulsants may be considered for patients with aneurysmal subarachnoid hemorrhage. In such cases, however, anticonvulsant should 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

Recommendation

• Currently, therefore, there is not enough evidence to justify the routine use of antiepileptic drugs to prevent seizures after stroke (evidence current to 08/2013)

References:

1. http://emedicine.medscape.com/article/1916662-treatment#d9
2. http://www.cochrane.org/CD005398/EPILEPSY_is-there-evidence-to-support-the-use-of-antiepileptic-drugs-for-the-primary-and-secondary-prevention-of-seizures-after-stroke
3. http://stroke.ahajournals.org/content/40/12/3810.full