Seizure prophylaxis in Spontaneous Intracerebral Hemorrhage

Neurocritical Care
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Sep 1, 2021
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  • Acute seizures are a common complication following spontaneous intracerebral hemorrhage (sICH).
  • The incidence of post ICH seizures rate is estimated to be between 4%-16%.
  • Current guidelines have limited recommendations due to the paucity of data.
  • Seizures generally develop early in Spontaneous ICH.
  • The association between the early seizure and late seizures/epilepsy remains unclear
Key Point
Limited evidence-based recommendations
Patient Profile: Cortical Bleed esp young patient
ASM of Choice: Levitricetam initial dose 750 mg PO/IV BID

Defining Seizure in sICH

Early Seizures and Prognosis

  • Early seizures are typically within seven days following sICH.
  • Frequency and risk factors for early seizures are poorly understood.

Recurrent Early seizures

  • An episode of more than one seizure within seven days of sICH.

Late Seizures:

  • Seizure onset after seven days following sICH.

PITCH Trail and Early Seizures

  • A prospective cohort study conducted by Herdt et al Prognosis of Intracerebral hemorrhage (PITCH trial) between Nov 2004- March 2009.
  • The study recruited 562 adult patients with sICH.
  • Patients with a previous history of seizures (n 40) were excluded from the study.
  • The strongest factor associated with ES was the cortical involvement of ICH.
  • Other factors associate with the onset of ES include younger age, previous ICH, the severity of neurological deficits at admission, and cortical involvement.
  • However, ES does not influence the functional outcomes for the 6 months in patients following sICH.
  • None of the patients received prophylactic treatment.

Prophylactic AED use

  • Almost 40% of the patients received antiepileptic drugs following intracerebral hemorrhage.
  • Prophylactic AED is not associated with any poor outcomes especially with the use of Levetiracetam.
  • Treatment duration is non-specific (short-term to long-term)

Tools to determine seizures risks

  • Early seizures prophylaxis is determined by using a risk stratification tool 2HELPS2B score.
  • Late seizures risk is determined by using the CAVE score (cortical involvement, age <65 years, volume of blood more than 10 ml, and early seizures).
  • These tools can help physicians in decision-making for seizure prophylaxis following sICH.

Seizures and Anti-seizure Drugs

Recommendations from AHA/ASA
  • Seizures should be treated with antiseizure drugs (Class I; Level of Evidence A).
  • Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with antiseizure drugs (Class I; Level of Evidence C).
  • Continuous EEG monitoring is probably indicated in ICH patients with a depressed mental status that is out of proportion to the degree Clinical of brain injury (Class IIa; Level of Evidence C). (Revised from the previous guideline)
  • Prophylactic anti-seizure medication is not recommended (Class III; Level of Evidence B). (Unchanged from the previous guideline)

Further Reading

Jones FJS, Sanches PR, Smith JR, et al. Seizure Prophylaxis After Spontaneous Intracerebral Hemorrhage. JAMA Neurol. 2021;78(9):1128–1136. doi:10.1001/jamaneurol.2021.2249


  • Gilmore, E. J., Maciel, C. B., Hirsch, L. J., & Sheth, K. N. (2016). Review of the Utility of Prophylactic Anticonvulsant Use in Critically Ill Patients With Intracerebral Hemorrhage. Stroke, 47(10), 2666–2672.
  • De Herdt, V., Dumont, F., Hénon, H., Derambure, P., Vonck, K., Leys, D., & Cordonnier, C. (2011). Early seizures in intracerebral hemorrhage: incidence, associated factors, and outcome. Neurology, 77(20), 1794–1800.
  • Sheth, K. N., Martini, S. R., Moomaw, C. J., Koch, S., Elkind, M. S. V., Sung, G., Kittner, S. J., Frankel, M., Rosand, J., Langefeld, C. D., Comeau, M. E., Waddy, S. P., Osborne, J., & Woo, D. (2015). Prophylactic Antiepileptic Drug Use and Outcome in the Ethnic/Racial Variations of Intracerebral Hemorrhage Study. Stroke, 46(12), 3532–3535.
  • Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, and Council on Clinical Cardiology. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:2032–2060.
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