Abstract
Background:Empiric use of anticonvulsant (AED) for seizure prophylaxis in aneurysmal subarachnoid hemorrhage (SAH) remains controversial and may be associated with worse SAH outcome. We determined the safety and feasibility of early discontinuation of empiric AED in a select cohort of SAH patients.Methods:In a cohort of 166 consecutive SAH patients, a subset underwent early AED discontinuation if they were awake and following commands after aneurysm treatment. We examined the effect of AED discontinuation on seizure incidence, mortality and functional outcome at discharge using logistic regression and validated results using 70%-30% data partition.Results:Seventy-three subjects underwent AED discontinuation. Patient groups had similar gender, age, Fisher grade, incidence of craniotomy, vasospasm, ischemic infarct, intraventricular and intraparenchymal hemorrhages. Hunt-Hess (HH) grade were lower in AED-discontinuation group. Clinical or electrographic seizure occurred in 1/93 (1%) patients on AED and 0/73 patient in AED-discontinuation group. Crude mortality was 24% in patients on AED and 2.7% off AED. After adjusting for age, HH grade, vasospasm, ischemic infarct, intracerebral, and intraventricular hemorrhage, AED discontinuation remains independently associated with lower mortality and higher odds of discharge to home (p=0.0002). AED use is not associated with angiographic vasospasm on exploratory analysis.Conclusion:AED discontinuation in SAH patients who are awake and following commands post aneurysm treatment is safe, feasible, and associated with better outcome at hospital discharge. A larger, prospective study is necessary to determine if empiric AED use in SAH leads to poorer functional status.
Highlights
Subarachnoid hemorrhage (SAH) affects 50,000 people yearly in the United States and affects up to 30/100,000 in other parts of the world such as Japan and Finland [1,2]
We utilized the introduction of a new clinical protocol that selectively discontinued AED in subarachnoid hemorrhage (SAH) patients who met the following eligibility criteria: i) older than 18 years of age, ii) had aneurysmal SAH or pre-pontine SAH, iii) the bleeding aneurysm(s) had been secured via surgical or endovascular intervention, iv) patient had had more than 24 hours to recover from surgical or endovascular procedure for cerebral aneurysm treatment, and v) patient was awake and following commands
We identified consecutive aneurysmal SAH patients admitted over a 2-year peroid through a prospective ICU database
Summary
Subarachnoid hemorrhage (SAH) affects 50,000 people yearly in the United States and affects up to 30/100,000 in other parts of the world such as Japan and Finland [1,2]. Reported incidence of SAHrelated seizures varies widely but may be as high as 25% [5], prompting most clinicians to empirically treat all SAH patients with prophylactic anticonvulsant (AED). Despite newer studies reporting a much lower seizure incidences in SAH [6], approximately 65% of all SAH patients still receive empiric AED therapy [7]. Emerging data suggest empiric use of prophylactic AED post SAH, even for a short time, is associated with worse functional outcome [7,10,11]. There has been no prospective clinical trial that examined the effect of prophylactic AED use and SAH outcome. Empiric use of anticonvulsant (AED) for seizure prophylaxis in aneurysmal subarachnoid hemorrhage (SAH) remains controversial and may be associated with worse SAH outcome. We determined the safety and feasibility of early discontinuation of empiric AED in a select cohort of SAH patients
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