Epilepsy after subarachnoid hemorrhage: the frequency of seizures after clip occlusion or coil embolization of a ruptured cerebral aneurysm

Results from the International Subarachnoid Aneurysm Trial 

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Object

The aim of this study was to determine the probability of seizures after treatment of a ruptured cerebral aneurysm by clip occlusion and coil embolization, and to identify the risks and predictors of seizures over the shortand long-term follow-up period.

Methods

The study population included 2143 patients with ruptured intracranial aneurysms who were enrolled in 43 centers and randomly assigned to clip application or coil placement. Those patients suffering a seizure were identified prospectively at various time points after randomization, as follows: before treatment; after treatment and before discharge; after discharge to 1 year; and annually thereafter.

Results

Two hundred thirty-five (10.9%) of the 2143 patients suffered a seizure after randomization; 89 (8.3%) of 1073 and 146 (13.6%) of 1070 in the endovascular and neurosurgical allocations, respectively (p = 0.014). In 19 patients the seizure was associated with a rehemorrhage. Of those patients who underwent coil placement alone, without additional procedures, 52 suffered a seizure, and in the group with clip occlusion alone, 91 patients suffered a seizure.

The risk of a seizure after discharge in the endovascular group was 3.3% at 1 year and 6.4% at 5 years. In the neurosurgical group it was 5.2% at 1 year and 9.6% at 5 years. The risk of seizure was significantly greater in the neurosurgical group at both 2 years and at up to 14 years (p = 0.005 and p = 0.013, respectively). The significant predictors of increased risk were as follows: neurosurgical treatment allocation, hazard ratio (HR) 1.64 (95% CI 1.19–2.26); younger age, HR 1.54 (95% CI 1.14–2.13); Fisher grade > 1 on CT scans, HR 1.34 (95% CI 0.62–2.87); delayed ischemic neurological deficit due to vasospasm, HR 2.10 (95% CI 1.49–2.94); and thromboembolic complication, HR 5.08 (95% CI 3.00–8.61). A middle cerebral artery (MCA) aneurysm location was also a significant predictor of increased risk in both groups; the HR was 2.23 (95% CI 1.57–3.17), with the probability of seizure at 6.1% and 11.5% at 1 year in the endovascular and neurosurgery groups, respectively.

Conclusions

The risk of seizures after coil embolization is significantly lower than that after clip occlusion. An MCA aneurysm location increased the risk of seizures in both groups.

Abbreviations used in this paper: CRF = case record form; DIND = delayed ischemic neurological deficit; ISAT = International Subarachnoid Aneurysm Trial; MCA = middle cerebral artery; mRS = modified Rankin Scale; SAH = subarachnoid hemorrhage; UK = United Kingdom; WFNS = World Federation of Neurosurgical Societies.

Article Information

Address correspondence to: Andrew J. Molyneux, F.R.C.R., Oxford Neurovascular and Neuroradiology Research Unit, Nuffield Department of Surgical Sciences, University of Oxford, Level 6, West Wing, Oxford Radcliffe Hospitals, National Health Service Trust, Oxford OX3 9DU, United Kingdom. email: andy.molyneux@nds.ox.ac.uk.

Please include this information when citing this paper: published online August 5, 2011; DOI: 10.3171/2011.6.JNS101836.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Flow diagram showing breakdown of all patients reporting seizures. VP = ventriculoperitoneal.

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    Kaplan-Meier graph of cumulative risk of seizure after discharge for patients followed for a minimum of 6 years and a maximum of 14 years after SAH, by treatment group.

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    Kaplan-Meier graph of cumulative risk of seizure after discharge for patients followed for a minimum of 6 years and a maximum of 14 years, by treatment group and the site of the aneurysm (MCA or other location).

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    Kaplan-Meier graph of cumulative risk of seizure after discharge for patients with an mRS score of 0, 1, or 2 at 2 months after SAH, followed for a minimum of 6 years and a maximum of 14 years by treatment group and the site of the aneurysm (MCA or elsewhere).

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