Prophylactic Use Of Antiepileptic Drugs Research Articles

Use of antiepileptic medications for seizures' prevention during subarachnoid hemorrhage: A retrospective observational study.

The use of prophylactic antiepileptic drugs (AEDs) post-subarachnoid hemorrhage (SAH), particularly aneurysmal SAH, is controversial, with limited data available. This has led the new American Heart Association/American Stroke Association (AHA/ASA) guidelines to recommend against using AEDs. This study is aimed at determining whether the use of AEDs for primary prophylaxis is effective in reducing the incidence of seizures post-SAH. A retrospective observational study was conducted utilizing a reviewing chart for the period starting from June 2015 to the end of 2021. The reviews were conducted in the acute care areas of 2 tertiary hospitals primarily to assess the efficacy of AEDs against seizures in patients with SAH (particularly aneurysmal SAH). This was done by comparing the occurrence of early, late, and overall incidence of seizures between patients who received AEDs versus those who did not. Of the 62 patients, who mostly presented with aneurysmal SAH (71%), 42 received AEDs and 20 did not. Mostly, the baseline characteristics between the 2 groups were comparable. A few patients on AEDs developed early (n = 4/38), late (n = 3/29), and overall seizures (n = 6/33), whereas no early, late, or overall incidence of seizures was presented in the group who did not receive AEDs. However, this difference showed no significance (P > .05). The subjects who were given AEDs showed significantly longer hospital stays (42.11 ± 51.43 vs 14.10 ± 7.17; P = .002) and higher mortality rates (7/11 vs 0/11; P = .026). For all patients who received AEDs for prophylaxis, the overall incidence of seizures was negatively associated with the Glasgow coma scale (OR: 0.798; 95% CI 0.657-0.978; P = .022). Our findings support the 2023 AHA/ASA guideline recommendation to avoid using routine AEDs for prophylaxis for all SAH patients. Proper and careful stratification methods should be implemented in each given scenario.

Comparison of Postoperative Seizures Between Burr-Hole Evacuation and Craniotomy in Patients With Nonacute Subdural Hematomas: A Bi-Institutional Propensity Score-Matched Analysis.

Postoperative seizures are a common complication after surgical drainage of nonacute chronic subdural hematomas (SDHs). The literature increasingly supports the use of prophylactic antiepileptic drugs for craniotomy, a procedure that is often associated with larger collections and worse clinical status at admission. This study aimed to compare the incidence of postoperative seizures in patients treated with burr-hole drainage and those treated with craniotomy through propensity score matching (PSM). A retrospective cohort analysis was conducted on patients with surgical drainage of nonacute SDHs (burr-holes and craniotomies) between January 2017 to December 2021 at 2 academic institutions in the United States. PSM was performed by controlling for age, subdural thickness, subacute component, and preoperative Glasgow Coma Scale. Seizure rates and accompanying abnormalities on electroencephalographic tracing were evaluated postmatching. A total of 467 patients with 510 nonacute SDHs underwent 474 procedures, with 242 burr-hole evacuations (51.0%) and 232 craniotomies (49.0%). PSM resulted in 62 matched pairs. After matching, univariate analysis revealed that burr-hole evacuations exhibited lower rates of seizures (1.6% vs 11.3%; P = .03) and abnormal electroencephalographic findings (0.0% vs 4.8%; P = .03) compared with craniotomies. No significant differences were observed in postoperative Glasgow Coma Scale (P = .77) and length of hospital stay (P = .61). Burr-hole evacuation demonstrated significantly lower seizure rates than craniotomy using a propensity score-matched analysis controlling for significant variables.

Functional outcome in patients with traumatic or hemorrhagic brain injuries undergoing decompressive craniectomy versus craniotomy and 6-month rehabilitation

Decompressive craniectomy (DC) and craniotomy (CT) to treat increased intracranial pressure after brain injury are common but controversial choices in clinical practice. Studying a large cohort of patients with traumatic brain injury (TBI) and hemorrhagic stroke (HS) on rehabilitation pathways, we aimed to determine the impact of DC and CT on functional outcome/mortality, and on seizures occurrence. This observational retrospective study included patients with either TBI, or HS, who underwent DC or CT, consecutively admitted to our unit for 6-month neurorehabilitation programs between January 1, 2009 and December 31, 2018. Neurological status using Glasgow Coma Scale (GCS), and rehabilitation outcome with Functional Independence Measure, both assessed at baseline and on discharge, post-DC cranioplasty, prophylactic antiepileptic drug use, occurrence of early/late seizures, infectious complications, and death during hospitalization were evaluated and analyzed with linear and logistic regression models. Among 278 patients, DC was performed in 98 (66.2%) with HS, and in 98 (75.4%) with TBI, whilst CT in 50 (33.8%) with HS, and in 32 (24.6%) with TBI. On admission, GCS scores were lower in patients treated with CT than in those with DC (HS, p = 0.016; TBI, p = 0.024). Severity of brain injury and older age were the main factors affecting functional outcome, without between-group differences, but DC associated with worse functional outcome, independently from severity or type of brain injury. Unprovoked seizures occurred post-DC cranioplasty more frequently after HS (OR = 5.142, 95% CI 1.026–25.784, p = 0.047). DC and CT shared similar risk of mortality, which associated with sepsis (OR = 16.846, 95% CI 5.663–50.109, p < 0.0001), or acute symptomatic seizures (OR = 4.282, 95% CI 1.276–14.370, p = 0.019), independently from the neurosurgery procedures. Among CT and DC, the latter neurosurgical procedure is at major risk of worse functional outcome in patients with mild-to-severe TBI, or HS undergoing an intensive rehabilitation program. Complications with sepsis or acute symptomatic seizures increase the risk of death.

Prophylactic Levetiracetam for the Prevention of Seizures in Acute Nontraumatic Intracerebral Hemorrhage: A Retrospective Propensity-matched Patient Outcome Analysis (P7-5.030)

<h3>Objective:</h3> This study aims to determine if prophylactic levetiracetam in nontraumatic intracerebral hemorrhage (nt-ICH) decreases seizure risk and improves mortality. <h3>Background:</h3> Early seizures is a common morbidity in nt-ICH, often associated with worsening neurological outcome. There are conflicting data on the use of prophylactic antiepileptic drugs (AEDs) in the form of levetiracetam in this population. Current guidelines do not endorse prophylactic AED use due to limited evidence for clinical benefit; however, they are routinely prescribed in the acute setting. <h3>Design/Methods:</h3> This was a retrospective cohort study using data collected from TriNetX, a deidentified patient database collated from 71 healthcare organizations. Using ICD-10 codes, we identified nt-ICH patients excluding those with a history of seizure disorders. Patients were dichotomized based on prophylactic levetiracetam use or not. Propensity score adjustment matched cohorts on age, sex, race, significant comorbidities, complications of nt-ICH, location of nt-ICH, and NIHSS score. Associations with mortality; occurrence of seizure, acute kidney injury (AKI), transient ischemic attack (TIA), stroke, myocardial infarction; percutaneous endoscopic gastrostomy and tracheostomy placement at day 30 were measured between groups using unadjusted odds ratios (OR) with 95% confidence intervals (CI). <h3>Results:</h3> This study identified 1,571 patients with nt-ICH who received prophylactic levetiracetam and 9,570 patients who did not. After matching, 1,492 patients remained in each cohort. Our analysis showed that prophylactic levetiracetam in patients with nt-ICH was not associated with decreased seizure occurrence (OR, 1.21 [95% CI, 0.88, 1.68]) or mortality benefit (OR, 1.06 [95% CI, 0.90, 1.25]); was associated with decreased incidence of AKI (OR 0.552 [95% CI 0.344, 0.884]) and TIA [OR 0.496 (95% CI 0.304, 0.807)]. <h3>Conclusions:</h3> This data suggests that prophylactic levetiracetam does not provide a mortality benefit or decrease the occurrence of seizures in the acute setting of nt-ICH. Prospective studies are necessary to confirm these findings and assess the impact on longitudinal functional outcomes. <b>Disclosure:</b> Miss Nguyen has nothing to disclose. Ms. Bhanja has nothing to disclose. Dr. Hallan has nothing to disclose. Kevin Cockroft has received personal compensation in the range of $5,000-$9,999 for serving as an officer or member of the Board of Directors for Intersocietal Accreditation Commission. The institution of Kevin Cockroft has received research support from Intersocietal Accreditation Commission. The institution of Kevin Cockroft has received research support from Nico Corporation. The institution of Kevin Cockroft has received research support from Idorsia Pharmaceuticals . The institution of Kevin Cockroft has received research support from AstraZeneca . Dr. Rizk has nothing to disclose.

Post traumatic pneumocephalus, its complications and management outcome: A prospective study in tertiary care center

To study clinical course and complications in patients diagnosed to have post-traumatic pneumocephalus based on: 1. Patterns of associated skull fractures; 2 Findings seen in CT scan which may be risk factors for development of CSFR, meningitis or tension pneumocephalus. To study clinical outcome in patients with PTP This prospective observational study was conducted over a period of 14 months from 15 Nov. 2017 to 15 Jan. 2019 in Goa Medical College, a tertiary care centre for the management of all kind of trauma patients including TBI. The study included all cases of TBI with CT head showing PTP alonwith there radiological findings, clinical course, complications and its management outcome. A total of 102 cases of post-traumatic pneumocephalus were included in the study. Motor vehicle accident was found to be major cause of PTP (79.41%). The most common site of post traumatic PTP was subdural (45.1%). Majority of the patients with PTP had focal PTP underlying the fracture segment (63.73%). Majority of the patients (30) had either isolated fracture frontal sinus (18) or multiple basal (12). CSFR was seen in 13 patients. Majority (74.51%) of patients were treated conservatively. Most of operative interventions were done for associated EDH, SDH, Contusion or diffuse brain injuries. Comminuted depressed fracture frontal sinus is most common fracture associated in patients with massive pneumocephalus and CSFR. All patients with evidence of post traumatic PTP and basal skull fracture must be followed over longer period as delayed onset TP, CSF leak and meningitis didn’t show any specific pattern with initial presentation.The use of prophylactic anticonvulsants should be based on the presence of other indications for it.Patients with PTP can be managed without prophylactic antibiotics which can be reserved then only for those with contaminated injuries.TP, CSF leak and meningitis are life threatening complications of PTP. Early recognition and high index of clinical suspicion and prompt treatment results in improvement of vast majority of patients.

Adherence to Prophylactic Anticonvulsant Guidelines for Newly Diagnosed Brain Tumor Patients: A Quality Improvement Study.

Clinical guidelines suggest that prophylactic antiepileptic drugs (AEDs) should be given to newly diagnosed seizure-naive brain tumor patients for up to 1 week after craniotomy. Yet, data suggest that prophylactic AEDs are used up to 12 months after surgery. A quality improvement project was implemented to improve adherence to evidence-based prophylactic AED guidelines. A quasi-experimental, pre- and post-test intervention design was used to assess the effect of a multiphase intervention on guideline adherence and prophylactic anticonvulsant prescription rates. The 16-week intervention consisted of provider education sessions, provider alerts, documentation templates, and a weekly audit and feedback. Participants included four providers and newly diagnosed seizure-naive brain tumor patients. Measures included guideline adherence rates and AED prescription rates extracted from chart review, and a provider attitude and knowledge survey. Analyses included descriptive statistics, Wilcoxon signed-rank tests, and Chi-square tests. Guideline adherence increased significantly (p < .01) from 4 months before implementation (15.8%) to 1 year before implementation (27.8%) and then to 93.3% after implementation. Provider knowledge showed clinically meaningful decreases in the likelihood to prescribe prophylactic AEDs (-.5 point) and increased understanding of prophylactic AED side effects (+0.5 point), although these were not statistically significant (p = .083). Finally, prophylactic AED prescription rates decreased by 2.2% (p = .119) compared with 4 months and 1 year before implementation (2.6%; p = .072). This project highlights the important role of provider education, provider alerts, a documentation template, and audit and feedback in improving guideline adherence rate. Findings suggest that the combination intervention and weekly audit and feedback strategy can improve guideline adherence to prophylactic anticonvulsant use in seizure-naive newly diagnosed brain tumor patients. By following prophylactic AED guideline recommendations, clinicians can avoid the potential side effects of anticonvulsant-induced cognitive, behavioral, and psychiatric issues that can impair patients' quality of life.

A Novel Radiographic and Clinical Assessment Scoring Tool for Seizure Risk Stratification in the Acute Phase of Cerebral Venous Sinus Thrombosis: A Systematic Review and Meta-Analysis

Background: Nearly 40% of cerebral venous sinus thrombosis (CVST) cases experience a seizure. A plethora of problems may arise from seizures. Many of these are well recognized in literature as well as in clinical practice. These include the risk for acute respiratory failure, acute renal injury, demand ischemia of myocardium, aspiration pneumonia, and a variety of musculoskeletal injury. Given the lack of a validated tool to predict seizure in the acute phase of CVST, the use of prophylactic anti-epileptic drugs (AEDs) is controversial. A systematic review and meta-analysis of observational studies was conducted to identify risk factors to construct a clinical prediction tool for seizure in acute CVST. Methods: Systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Observational studies that investigated the risk factors for seizure in acute CVST were retrieved from MEDLINE, EBSCO, Web of Science, and Pro-Quest. The summary odds ratios (ORs) were calculated from the pool of data under the random effects model. A point value of 1, 2, or 3 was assigned to each risk factor based on their β-coefficient in the predictive model. Discriminative ability of this model was evaluated on the receiver operating characteristic curve. Results: Initial literature search revealed 1,046 articles discussing seizure as a complication of acute CVST. Through a robust systematic review process with two independent reviewers, 14 studies fully meeting the inclusion criteria were selected. Data elements extracted from the studies were analyzed and re-synthesized. Anatomical involvement of frontal lobe (OR: 4.85; 95% confidence interval (CI): 3.52 - 6.68), parietal lobe (OR: 2.52, 95% CI: 1.41 - 4.52), cortical vein thrombosis (OR: 3.16, 95% CI: 2.18 - 4.58), hemorrhagic venous ischemia (OR: 3.85; 95% CI: 3.20 - 4.64), and clinical presentation of motor deficit (OR: 3.07; 95% CI: 2.66 - 3.55) or confusion (OR: 2.15; 95% CI: 1.57 - 2.94) showed a strong association with increased risk for seizure in the setting of acute CVST. We developed a novel Radiographic and Clinical Assessment (RC) scoring system, consisting of the significant six risk factors. RC score yielded a calculated area under the curve of 0.89, with probabilities for seizure ranging from 40% with a score of 0 to 92% for score of 6. Conclusions: RC scoring tool can be used to stratify the seizure risk based on radiographic findings and the clinical presentation in the acute phase of CVST. This predictive tool may be helpful in identifying patients whose seizure risk is high and can potentially further be used as a clinical decision support tool for prophylactic AED treatment. J Neurol Res. 2022;12(3):114-120 doi: https://doi.org/10.14740/jnr731

Seizure after surgical treatment of chronic subdural hematoma-Associated factors and effect on outcome.

IntroductionChronic subdural hematoma (cSDH) is becoming more prevalent due to population aging and the increasing use of antithrombotic drugs. Postoperative seizure in cSDH have a negative effect on outcome, and there currently no consensus regarding prophylactic anti-epileptic drug (AED) treatment. The objective of this study was to evaluate predisposing and triggering factors associated with postoperative epileptic seizure in patients with cSDH.MethodsAll patients, who were surgically treated for cSDH in a single tertiary care center between 2015 and 2019, were considered for inclusion. Relevant patient- and hematoma-specific characteristics were retrospectively extracted from hospital records. Paroxysmal events categorized by the treating physician as suspected postoperative seizures were noted. The clinical outcome was extracted from the last available follow-up visit and classified according to the Glasgow outcome scale (GOS).ResultsOf the included 349 patients, 54 (15.5%) developed suspected postoperative epileptic complications in the form of early seizure (≤ 7 days) in 11 patients (3.2%) and late seizure (>7 days) in 43 patients (12.3%). In the logistic regression analysis, solely depressed brain volume (supratentorial volume (ml) not filled with re-expanded brain) was independently associated with postoperative seizure (odds ratio [OR] 1.006, 95% CI: 1.001–1.011; p = 0.034). The occurrence of postoperative seizure (OR 6.210, 95% CI: 2.704–14.258; p < 0.001) and preoperative Markwalder grading (OR 2.919, 95% CI: 1.538–5.543; p = 0.001) were independently associated with unfavorable (GOS1−3) outcome.ConclusionLarger postoperative depressed brain volume was the only factor independently associated with suspected postoperative seizure, and it could help identify a subgroup of patients with higher susceptibility to epileptic events. Based on our data, no formal recommendation can be made regarding the prophylactic use of anti-epileptic drugs. Nevertheless, the relative safety of new generation AEDs and the detrimental effect of postoperative seizure on outcome may justify its use in a selected patient population.

A nationalsurveyandresults analysisof seizure prophylaxis after aneurismal subarachnoid hemorrhage

Investigate theclinical practice of seizure prophylaxis after aneurysmal subarachnoid hemorrhage in Chinese neurosurgeons.Aquestionnaire for this theme was designed and was sent to respondents through the internet.From July 2021 to October 2021, atotal of forty-three eligible questionnaires were collected. All responders come from affiliated hospitals of medical schools in China. Each of these hospitals admitted more than one hundred patients with aneurysmal subarachnoid hemorrhage per year. Only 9.3% (4/43) of responders disagree with the prophylactic use of anticonvulsants. 86.04% (37/43) of responders perform seizure prophylaxis in clinical practice. Sodium valproate is the most commonly used regimen; 94.59% (35/37) of responders who perform prophylaxis chose this drug. The medication period differs sharply fromlessthan 3 daystolongerthan 14 daysamong different hospitals. The use of EEG was insufficient in Chinese patients. A low seizure rate was reported according to the feedback from Chinese neurosurgeons.In China, seizure prophylaxis after subarachnoid hemorrhage was not yet standardized. Clinicians' mastery of relevant knowledge is still not enough. Carrying out high-quality clinical research can help justify the use of anticonvulsants, which could also positively impact rational drug use.

Occurrence of early epilepsy in children with traumatic brain injury: a retrospective study.

Early post-traumatic seizures (EPTS) refer to epileptic seizures occurring within one week after brain injury. This study aimed to define the risk factors of EPTS and the protective factors that could prevent its occurrence. This is a single-center retrospective study in thePICU, Beijing Children's Hospital. Patients diagnosed with traumatic brain injury (TBI), admitted with and without EPTS between January 2016 and December 2020 were included in the study. We included 108 patients diagnosed with TBI.The overall EPTS incidence was 33.98% (35/108). The correlation between EPTS and depressed fractures is positive (P = 0.023). Positive correlations between EPTS and intracranial hemorrhage and subarachnoid hemorrhage had been established (P = 0.011and P = 0.004, respectively). The detection rates of EPTS in the electroencephalogram (EEG) monitoring was 80.00%. There was a significant difference in the EEG monitoring rate between the two groups (P = 0.041). Forty-one (37.86%, 41/108) post-neurosurgical patients were treated with prophylactic antiepileptic drugs (AEDs), and eight (19.51%, 8/41) still had seizures. No statistical significance was noted between the two groups in terms of prophylactic AEDs use (P = 0.519). Logistic regression analysis revealed that open craniocerebral injury and fever on admission were risk factors for EPTS, whereas, surgical intervention and use of hypertonic saline were associated with not developing EPTS. Breakthrough EPTS occurred after severe TBI in 33.98% of pediatric cases in our cohort. This is a higher seizure incidence than that reported previously. Patients withfever on admission and open craniocerebral injuries are more likely to develop EPTS.

Developing guidelines for the management of brain tumour related epilepsy

Abstract Aims Brain Tumour Related Epilepsy (BTRE) has a significant impact on Quality of Life with implications for driving, employment and social and domestic activities. Management of BTRE is complex due to the higher incidence of pharmacoresistance and the potential for interaction between anti-cancer therapy and anti-epileptic drugs (AEDs). Neurologists, oncologists, palliative care physicians and clinical nurse specialists treating these patients would benefit from up-to-date clinical guidelines. We aim to review the current evidence to adapt current NICE guidelines for Epilepsy and to outline specific recommendations for the optimal treatment of BTRE, encompassing both primary and metastatic brain tumours. Method A comprehensive search of the literature from the past 20 years on BTRE was carried out in three databases: Embase, Medline and EMCARE. A broad search strategy was used and the evidence was evaluated and graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Results All patients with BTRE should be treated with AEDs. There is no proven benefit for the use of prophylactic AEDs, although there are no randomised trials testing newer agents. Seizure frequency varies between 10-40% (Class 2a evidence) in patients with Brain Metastases (BM) and from 30% (high-grade gliomas) to 90% (low-grade gliomas) (Class 2a evidence) in patients with Primary Brain Tumours (PBT). In patients with BM, risk factors include number of BM and melanoma histology (Class 2b evidence). In patients with PBT, risk factors include frontal and temporal location, oligodendroglial histology, IDH mutation and cortical infiltration (Class 2b evidence). There is a low incidence of seizures (13%) after stereotactic radiosurgery for BM (Class 2b evidence). Non-enzyme inducing AEDs are recommended as first line treatment for BTRE, but up to 50% of patients with BTRE due to PBT remain resistant (Class 2b evidence). Conclusion The review has highlighted the relative dearth of high quality evidence for the management of BTRE, and provides a framework for further studies aiming to improve seizure control, quality of life, and indications for AEDs.

Patterns of prophylactic anticonvulsant use in spontaneous intracerebral and subarachnoid hemorrhage: results of a practitioner survey.

The use of prophylactic anti-seizure medications (ASMs) in the management of patients with spontaneous intracerebral hemorrhage (sICH) and aneurysmal subarachnoid hemorrhage (aSAH) is controversial. The purpose of this survey was to better characterize the current state of prophylactic ASM use in sICH and aSAH in North America. US and Canadian neurosurgeons, neurologists, and interventional neuroradiologists with an interest in or expertise in the management of neurovascular disease were surveyed using an electronic survey tool. Seven hundred ninety-four survey requests were sent; responses were received from 103 (13%). The majority of respondents were neurosurgeons (84%). Thirty-eight percent of respondents self-identified as vascular neurosurgeons and 10% self-identified as neurocritical care specialists. Seventy-two percent were in academic practice. When asked their preference for ASM prophylaxis (aSAH, sICH, or both), the most common response was to use prophylaxis in both aSAH and sICH (43, 45%). Twenty-one (22%) did not use routine prophylaxis, while 22 (23%) used prophylaxis only in aSAH and 9 (9%) only in sICH. The majority of practitioners (35, 67%) who answered that they used ASM prophylaxis in sICH, used ASMs selectively. For aSAH, the vast majority (53, 82%) used prophylaxis for all patients. Respondents felt that they were more likely to use ASMs for sICH patients if the sICH was in a cortical location, supratentorial location, or was related to a structural abnormality (e.g., tumor, arteriovenous malformation) Levetiracetam (Keppra) was the most commonly used ASM (73, 99%). When asked whether the statement "Current AHA/ASA Guidelines recommend against the use of prophylactic anticonvulsants in spontaneous ICH" was true or false, 78 (83%) responded correctly that the recommendation is true. Only 24 respondents answered the question as to whether they would be willing to randomize sICH and/or aSAH patients to management with or without ASM prophylaxis. Of these, 13 (54%) said they would be willing to randomize sICH patients, while only 6 (25%) were willing to randomize aSAH patients. There were no statistically significant differences in responses to survey questions when analyzed by practice type (academic versus non-academic) or physician specialty (critical care versus non-critical care, or vascular neurology/neurosurgery versus other). The use of ASMs for seizure prophylaxis after sICH and aSAH remains widespread despite the lack of any specific evidence-based guideline to support the practice. A large-scale randomized controlled trial is needed to add clarity to the practice of prophylactic ASM use in patients with spontaneous intracranial hemorrhage.

The effect of prophylactic antiepileptic medications in aneurysmal subarachnoid hemorrhage patients: A retrospective review

ObjectiveThe current literary evidence suggests but does not heavily endorse the use of prophylactic antiepileptic drugs (AEDs) after aneurysmal subarachnoid hemorrhage. Literature continues to emerge suggesting not only a lack of efficacy but associated poor outcomes. This study is a retrospective review comparing seizure incidence in aneurysmal subarachnoid patients between those given prophylactic AEDs and those not. MethodsWith IRB approval, a retrospective chart review was performed on all aneurysmal subarachnoid patients from 2012 to 2019 at the University of Mississippi Medical center. Univariate and Multivariate analysis was performed using SAS. Primary outcome was seizure incidence between groups. Factors associated with seizure and poor outcome were also investigated. Results348 patients were identified: 120 in the AED group, and 228 patients in the non-AED group. There was no significant difference in mean age, gender, ethnicity, HH scores, treatment modality, or mean aneurysm size. The AED group had a higher history of prior aneurysmal rupture (6.7% vs. 1.3%, p = 0.01) and associated intracranial hemorrhage (22.5% vs. 10.5%, p = 0.0004). There was no significant difference in seizure incidence between the two groups (8.3% vs. 4.8%, p = 0.24). On multivariate analysis, aneurysm clipping compared to coiling (OR 3.8, p = 0.012) and delayed cerebral ischemia (OR 2.77, p = 0.023) were associated with seizures. DCI (OR 8.34), HH grade, Age (OR 1.07), Seizure (8.34), and AED use (1.7) were significantly associated with poor outcome. ConclusionThis retrospective review adds to the evidence that prophylactic AED use in aneurysmal subarachnoid hemorrhage patients has not been proven to improve seizure rates and may result in worse patient outcomes.

Duration and choices of prophylactic anticonvulsants in subarachnoid hemorrhage: a systematic review and meta-analysis.

The use of prophylactic anticonvulsants among patients with subarachnoid hemorrhage (SAH) is controversial. We sought to assess the effectiveness of different durations of prophylactic antiepileptic drug (AED) use among SAH patients. We searched the MEDLINE, Embase, Cochrane, and ClinicalTrials.gov databases until March 1, 2020. Randomized controlled trials or observational studies comparing different durations or different drugs were selected. The primary outcome was poor clinical outcomes. The secondary outcome was in-hospital seizure. Bayesian network meta-analysis was also performed to indirectly compare the effectiveness of different prophylaxes. A total of 5 papers were included. Three studies with a total of 959 patients were included in the analysis of the primary outcome; the results showed that long-term exposure to prophylactic AEDs (more than 3days) led to poor clinical outcomes (OR 1.55; 95% CI 1.01-2.39; p= 0.045). Four studies with 1024 patients were included in the analysis of the secondary outcome; the results showed no association between the duration of prophylactic AED use and the occurrence of in-hospital seizures (OR 0.62; 95% CI 0.18-2.15; p= 0.447). In the network meta-analysis, no significant difference was found among the four different prophylaxes. Our findings suggested that, when compared with the short-term use, the long-term use of prophylactic AEDs in SAH patients has a similar effect on in-hospital seizure prevention but is associated with poor clinical outcomes. However, these findings were based on a small number of available studies with obvious heterogeneity in study design and different prescription regimens. Further well-designed studies are warranted to elucidate these questions.

Seizures after posterior fossa surgery: Exploring the unknown: A systematic review

Background: Seizures due to posterior fossa lesions is an uncommon phenomenon. In this study, a systemic literature review was done to (i) study the incidence of seizures in posterior fossa lesions, (ii) determine factors associated with high risk for seizures, and (iii) ascertain the role of prophylactic antiepileptic drugs (AEDs) in such cases. Methods: Systemic literature review was done, for the MeSH terms “posterior cranial fossa” AND “seizures” AND “anticonvulsants.” All original research articles, case reports, and systematic reviews pertaining to seizures or the use of anticonvulsants in posterior fossa lesions were considered for inclusion. Results: A total of 79 cases of posterior fossa lesions, identified from 8 studies, were included for analysis. The incidence of seizures in posterior fossa lesions ranged from 1.8% to 5% in various studies. The highest incidence for seizures was reported with medulloblastoma, cerebellar hemorrhage, and during microvascular decompression for cases of neurovascular conflict. The most significant risk factor for seizures in the postoperative period was the use of ventricular shunt or ventriculostomy. AEDs were administered symptomatically after the occurrence of seizures in 78 cases except for the use of prophylactic AEDs in a single case of posterior cranial fossa lipoma. Conclusion: Seizures in association with posterior fossa lesions are rare and associated with a poor prognosis. Clinical detection can often be difficult and electroencephalogram helps in early diagnosis and treatment. Further studies are needed to confirm the role of prophylactic AEDs in high-risk cases.

Role of prophylactic antiepileptic drugs in chronic subdural hematoma-a systematic review and meta-analysis.

Chronic subdural hematoma is a common neurosurgical pathology, which is more commonly seen in the elderly age group. Few patients with chronic subdural hematoma (cSDH) can have seizures-either before or after surgical intervention. Reported incidence of seizures varies from 0.7-18.5% in patients with cSDH. Many factors which have been proposed to increase the risk of seizures in these patients include the presence of encapsulated membranes, occult cortical injury, mass effect, or an acute hemorrhage. The role of prophylactic antiepileptic drugs is not very clear in cSDH. We reviewed the currently available evidence for the use of prophylactic antiepileptic drugs (AEDs) in patients with cSDH. We included 13 studies in the systematic review and 6 studies compared the incidence of seizures in patients who received antiepileptic drugs with those who did not. Our review did not find any significant reduction in the incidence of seizures in patients with cSDH following administration of antiepileptic drugs.

Neuro-Oncology Practice Clinical Debate: long-term antiepileptic drug prophylaxis in patients with glioma.

Patients with primary brain tumors often experience seizures, which can be the presenting symptom or occur for the first time at any point along the illness trajectory. In addition to causing morbidity, seizures negatively affect independence and quality of life in other ways, for example, by leading to loss of driving privileges. Long-term therapy with antiepileptic drugs (AEDs) is the standard of care in brain tumor patients with seizures, but the role of prophylactic AEDs in seizure-naive patients remains controversial. In this article, experts in the field discuss the issues of AED efficacy and toxicity, and explain their differing recommendations for routine use of prophylactic AEDs.

Short-term risk of relapse after a first unprovoked seizure in an adult population

To evaluate the incidence of short-term recurrence (<1 month) after a first unprovoked seizure (FUS) and the associated risk factors. This is a prospective monocentric one-year observational study on all consecutive adult patients admitted to the Emergency Department (ED) and diagnosed as FUS. Patients underwent neurological consultation at one and three months after the FUS. Demographic information, clinical examination and seizure features, seizure recurrence at 1 and 3 months, electroencephalogram (EEG), brain imaging, precipitating factors, seizure type, and prescribed antiepileptic drugs (AED) were prospectively collected. Among 140 patients diagnosed as FUS, 109 patients attended the neurological consultation at 1 month. FUS diagnosis was confirmed in 80/109 cases. Nine patients (11.2%) had seizure recurrence before the consultation at 1 month. Identified specific risk factors of short-term recurrence were focal seizure (P=0.015) and abnormal EEG in the first 48hours (P=0.048). In the group of patients followed for three months (38 patients), the risk of seizure relapse was 15.7%. Most patients with FUS diagnosed in the ED did not present seizure recurrence within the first month, especially if no specific risk factors were present (focal seizure, abnormal EEG within first 48hours). The systematic use of prophylactic AED (benzodiazepines) is not recommended in the ED in the clinical setting of FUS. A specialized consultation within a one-month period is safe and adequate for FUS follow-up.

Abstract TP164: Statins for the Prevention of Post-Stroke Seizure and Epilepsy Development: A Systematic Review and Meta-Analysis

Introduction: Cerebrovascular disease is the leading cause of seizures and incident epilepsy of known etiology in older adults. As prophylactic use of antiepileptic drugs remains controversial, statins have garnered attention as an alternate preventive strategy due to pleiotropic effects, beyond lipid-lowering, which may include neuroprotective and anti-epileptogenic properties. Our objective was to assess the current evidence on statin use for prevention of post-stroke seizure and post-stroke epilepsy (PSE). Methods: We conducted a systematic review following PRISMA guidelines. Pubmed and Embase were searched from database inception to May 2019 for English-language, full-text experimental, observational analytic, or systematic reviews/meta-analytic studies examining the association between statin use in adults and development of early-onset seizures (ES; seizures ≤7 days after stroke) or PSE. Pooled analyses were based on random-effects models using the inverse-variance method. Results: Of 157 citations, 154 were excluded due to duplication or ineligibility, yielding 3 cohort studies from East Asia. Two studies reported on outcomes of ischemic stroke and 1 on hemorrhagic stroke. Only 1 study reported on ES, finding a significantly reduced risk following post-stroke statin use (OR 0.35, CI 0.20-0.60). Two studies reported on pre-stroke statin use, with findings demonstrating a lack of association with PSE (pooled OR 1.17, CI 0.93-1.48; Figure 1.1). However, post-stroke statin use was associated with less PSE (pooled OR 0.61, CI 0.50-0.74), without evidence of heterogeneity (Figure 1.2). Conclusions: Systematic review and meta-analysis of 3 high-quality cohort studies suggests post-stroke, but not pre-stroke, statin use may be associated with reduced risk of PSE. Further research is warranted to verify if these findings are replicable in other populations, as well as to explore the influence of timing and duration of statin use on outcomes.

Risk factors for early-onset seizures in patients with cerebral venous sinus thrombosis: A meta-analysis of observational studies

PurposeWe conducted a meta-analysis to determine the predictors of early-onset seizure in patients with cerebral venous sinus thrombosis (CVST) and to provide a basis for further clinical trials of prophylactic use of antiepileptic drugs in patients with CVST. MethodThe meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Relevant observational studies that investigated risk factors for early-onset seizures after CVST were retrieved from Pubmed and Embase databases. Odds ratios (OR) for early-onset seizures were calculated from the pooled data using the random effects model. ResultsSix observational studies (combined n = 1244) were included in this meta-analysis. Coma [OR, 2.265; 95% confidence interval (CI) 1.251–4.100], mental status (OR, 3.450; 95% CI 1.150–10.356), motor symptoms (OR, 3.726; 95% CI 2.519–5.514), involvement of cortical veins (OR, 3.574; 95% CI 2.521–5.068), supratentorial lesion (OR, 5.041; 95% CI 3.622–7.015), frontal lobe (OR, 3.481; 95% CI 1.703–7.114), parietal lobe (OR, 3.638; 95% CI 1.911–6.925), hemorrhagic lesions (OR, 2.505; 95% CI 1.485–4.225), and pregnancy (OR, 2.054; 95% CI 1.043–4.048) showed a significant association with early-onset seizures. ConclusionInvolvement of a numer of specific cortical regions in the post-CVST phase may induce early-onset seizures, especially in the setting of concomitant hemorrhagic infarct or cortical vein involvement.