Seizures after intracerebral hemorrhage; risk factor, recurrence, efficacy of antiepileptic drug
Introduction
Post stroke seizures (PSS) are occasionally associated with intracerebral hemorrhage (ICH), with some patients having recurrent PSS. However, the risk factors of recurrent seizure for patients with an initial PSS after first ever ICH, and the effects of antiepileptic drugs (AED) for preventing recurrence of PSS, remains limited.
Electrographic seizures occur in 28% of patients with ICH during the initial 72 h after admission [1], and may be associated with expanding hemorrhages and periodic electrical discharges during cortical ICH [2]. PSS are commonly classified as early and late seizure (ES and LS) based on the differences of their timing after stroke. An arbitrary cut point of 1 or 2 weeks after the presenting stroke has been recognized to distinguish between them. Previous studies have reported that the incidence rate of seizures after ICH is 2.7–18.7% [3], [4], [5], [6], [7], [8], [9], with ES occurring in 2.7–17%, after ICH and the majority of seizures occurring at, or near, the onset of ICH [1], [3], [4], [5], [8]. The incidence rate of LS after ICH is reported to be 2.0–26.1%, and the wider variance is attributed to the divergent definitions of LS between studies [3], [4], [6], [9], [10], [11], [12]. Several studies report that the factors provoking seizures following ICH are related to hemorrhage volume, hemorrhage location within the cerebrum, cortical involvement, and the severity of neurological deficits [5], [11], [12], [13], [14].
There are also several previous reports on the effects of AED for seizures associated with ICH. Prophylactic administration of AED for lobar ICH reduces clinical seizures [5]. Short-term prophylactic AED therapy during the acute stage of ICH is effective for patients, because the seizures lead to additional damage such as herniation or re-bleeding [15]. However, these reports did not show the correlation between AED therapy in acute state and long-term outcome. Prospective and population-based studies do not show clear evidence for the direct influence of clinical seizures on neurological outcome or mortality [6], [9], [13], [16], which may suggest the benefit little from AED therapy. Several reports have examined the preventative effects of AED therapy on the development of recurrent PSS, which showed prophylactic AED therapy was not significantly associated with outcome [17], [28], [19]. The clinical decision about beginning and/or continuing AED therapy for an initial PSS after ICH is an important issue. This study aimed to determine the risk factors for recurrence of PSS and the efficacy of AED to prevent the recurrent PSS for patients having ICH with ES and LS.
Section snippets
Study population and design
This retrospective study analyzed hospitalized patients enrolled in our stroke registry from January 2004 to April 2012. The study sample consisted of 1920 patients with ICH. Exclusion criteria for ICH consisted of the following: (1) traumatic ICH, (2) subarachnoid hemorrhage, subdural hematoma, hemorrhagic infarct, or inflammatory vascular diseases, and (3) ICH caused by a primary or metastatic brain tumor. All records regarding subsequent hospitalization and death were reviewed. For the
Total patient cohort
The total number of patients with spontaneous ICH was 1920, comprising 1103 men (mean age 65.7 ± 13.8 years) and 817 women (mean age 71.9 ± 14.1 years). In this study, seizures occurred in 127 cases (6.6%). The interval from the onset of ICH to initial PSS was 0–78.5 months (mean 6.1 ± 13.8 months). Sixty-five cases had PSS at onset, and 72 had PSS within 24 h of onset. ES and LS were present in 83 (4.3%) and 44 cases (2.3%), respectively. Patients with PSS were significantly younger (62.1 ± 18.1 vs. 68.8 ±
Discussion
The present study demonstrates that the incidence of PSS in 1920 patients with ICH is 6.6%, and that seizures occur frequently following a cortical hemorrhage, non-hypertensive hemorrhage, severe neurological deficits, or in young patients. ES and LS occurred in 4.3% and 2.3% of the total ICH patient cohort, respectively, and 15.7% of the patients with an initial seizure developed recurrent PSS. In the present study, ES occurred in 4.3% of patients, which is consistent with past reports [4], [5]
Conclusion
Seizures are an important neurological complication of spontaneous ICH. The incident rates of ES and LS were 4.3% and 2.3%. Initial seizures in patients with ICH significantly correlated with cortical involvement of the cerebral lesion, non-hypertensive ICH, younger age, and severe neurological deficits. Of the patients with an initial seizure, 15.7% had recurrent PSS. Larger hematoma volume was the only predictive factor for recurrence of PSS. AED therapy when administered after the initial
Conflicts of interest/disclosures
On behalf of all authors, the corresponding author states that there is no conflict of interest.
Acknowledgments
We are grateful to Mrs. Tomoko Fukushima for providing statistical analysis and help for this study.
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2021, SeizureCitation Excerpt :Furthermore, as more studies were added, we did not observe the same efficacy. We observed that the early 3 studies also reported relatively higher ICH volumes or higher percentages of patients with IVH or both; both of these factors have been shown to be associated with a higher risk of seizures after spontaneous ICH 7,16,24]. Thus, we now hypothesize that seizure prophylaxis may be more effective in patients with more severe disease and in those at higher risk of seizure occurrence.
- 1
Present address: Department of Clinical Neuroscience and Therapeutics, Hiroshima
University Graduate School of Biomedical Sciences, Hiroshima, Japan.