Elsevier

Journal of Critical Care

Volume 24, Issue 3, September 2009, Pages 335-339
Journal of Critical Care

Predictors of seizure onset after intracerebral hemorrhage and the role of long-term antiepileptic therapy

https://doi.org/10.1016/j.jcrc.2008.10.015Get rights and content

Abstract

Objective

Seizures are a common complication after hemorrhagic stroke that may slow recovery and decrease quality of life. Recent evidence suggests that early- and late-onset seizures have distinct etiologies, rendering the role of prophylactic long-term antiepileptic drugs controversial. We investigated predictors of early- and late-onset seizures after evacuation of intracerebral hemorrhage (ICH) in an attempt to guide antiepileptic drug management in this patient population.

Methods

We performed a retrospective analysis of 110 patients admitted to Columbia University Medical Center between 1999 and 2007 for ICH and subsequent clot evacuation. Patients were included if they had a head computed tomography indicating ICH, an operative note confirming surgical evacuation, and sufficient medical records to determine seizure status. Demographic, clinical, and radiographic findings were recorded. Univariate and multivariate logistic regression analyses were used to determine factors associated with early- and late-onset electrographic and clinical seizures.

Results

Seizures occurred in 41.8% of patients, 29.6% of which had clinical manifestations and 16.3% of which were recorded on continuous electroencephalogram (EEG). After controlling for demographic factors, multivariate analysis identified 3 factors that were predictive of early-onset seizures (volume of hemorrhage, presence of subarachnoid hemorrhage, and subdural hemorrhage) and 2 factors that were predictive of late onset seizures (subdural hemorrhage and increased admission international normalized ratio (INR)).

Conclusions

The presence of subdural hematoma and increased INR is predictive of late-onset seizures in patients undergoing clot evacuation after ICH. The use of long-term antiepileptic therapy should be further studied in patients with these radiographic and clinical characteristics.

Introduction

Intracerebral hemorrhage (ICH) accounts for approximately 10% to 20% of stroke [1]. Despite best available therapy, ICH continues to cause considerable morbidity and mortality, with estimates of 30-day mortality ranging from 30% to 52%. Those patients who do survive typically have some degree of neurological disability, with only 20% regaining independence by 6 months [2]. Adding to this burden, up to one third of patients develop early- or late-onset seizures, which inhibit recovery and decrease quality of life [3], [4].

The decision to discharge patients with ICH on long-term antiepileptic medical therapy remains controversial, with recent evidence suggesting antiepileptic drugs (AEDs) may slow cognitive rehabilitation [5], [6], [7]. Despite this controversy, there are relatively few studies examining predictive factors that would allow clinicians to use medical therapy more judiciously [4], [8]. Furthermore, most investigations have focused only on early-onset seizures, occurring within 1 to 2 weeks of the initial ictus, although recent evidence suggests that early- and late-onset seizures have different etiologies. Early seizures are attributed to structural disruption and cellular biochemical dysfunction, whereas late seizures are related to gliosis and the development of meningocerebral cicatrix [9], [10]. To this end, we investigated potential predictors of both early- and late-onset seizures in surgically treated patients with ICH.

Section snippets

Study subjects

We retrospectively identified all patients with ICH who underwent clot evacuation at Columbia University Medical Center between January 1999 and November 2007 by a single surgeon (E.S.C.). Patients were included if they had a head computed tomography (CT), an operative note detailing clot evacuation, and sufficient medical records to determine clinical and demographic variables. This retrospective analysis was performed with the approval of the hospital Institutional Review Board.

Clinical management

Patients were

Results

Between January 1, 1999, and August 20, 2007, 110 patients underwent surgical evacuation for ICH. Twelve patients were excluded due to unobtainable head CT or insufficient records. The demographic and radiographic characteristics of the study population are shown in Table 1. Early-onset seizures (<14 days) occurred in 31 (31.6%) patients; late onset (>14 days) seizures occurred in 10 (10.2%) patients. A total of 29 (29.6%) seizures had clinical correlations, and 16 (16.3%) were captured on EEG.

Discussion

Seizure is a common complication after ICH that slows recovery and decreases quality of life. The decision to discharge patients with ICH on long-term antiepileptic medical therapy remains controversial, however, with recent evidence suggesting AEDs may slow cognitive rehabilitation [5], [6], [7]. Despite this controversy, there are relatively few studies examining predictive factors that would allow clinicians to use medical therapy more judiciously [4], [8]. To this end, we investigated

Acknowledgment

Matthew Garrett and Maxwell Merkow were supported by a Doris Duke Fellowship Grant.

References (15)

  • CaplanL.R.

    Intracerebral haemorrhage

    Lancet

    (1992)
  • BrailowskyS. et al.

    Phenytoin increases the severity of cortical hemiplegia in rats

    Brain Res

    (1986)
  • MayerS.A. et al.

    Treatment of intracerebral haemorrhage

    Lancet Neurol

    (2005)
  • HaysA. et al.

    Elevated troponin levels are associated with higher mortality following intracerebral hemorrhage

    Neurology

    (2006)
  • ArmstrongK.K. et al.

    Rehabilitation outcomes in patients with posttraumatic epilepsy

    Arch Phys Med Rehabil

    (1990)
  • ClaassenJ. et al.

    Electrographic seizures and periodic discharges after intracerebral hemorrhage

    Neurology

    (2007)
  • GoldsteinL.B.

    Common drugs may influence motor recovery after stroke. The sygen in acute stroke study investigators

    Neurology

    (1995)
There are more references available in the full text version of this article.

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