Clinical, laboratory, and radiographic predictors of the occurrence of seizures following aneurysmal subarachnoid hemorrhage

Clinical article

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Object

At present, the administration of prophylactic antiepileptic medication following aneurysmal subarachnoid hemorrhage (SAH) is controversial, and the practice is heterogeneous. Here, the authors sought to inform clinical decision making by identifying factors associated with the occurrence of seizures following aneurysm rupture.

Methods

Exploratory analysis was performed on 413 patients enrolled in CONSCIOUS-1 (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring after Subarachnoid Hemorrhage), a prospective randomized trial of clazosentan for the prevention of angiographic vasospasm. The association among clinical, laboratory, and radiographic covariates and the occurrence of seizures following SAH were determined. Covariates with a significance level of p < 0.20 on univariate analysis were entered into a multivariate logistic regression model. Receiver operating characteristic (ROC) curve analysis was used to define optimal predictive thresholds.

Results

Of the 413 patients enrolled in the study, 57 (13.8%) had at least 1 seizure following SAH. On univariate analysis, a World Federation of Neurosurgical Societies grade of IV–V, a greater subarachnoid clot burden, and the presence of midline shift and subdural hematomas were associated with seizure activity. On multivariate analysis, only a subarachnoid clot burden (OR 2.76, 95% CI 1.39–5.49) and subdural hematoma (OR 5.67, 95% CI 1.56–20.57) were associated with seizures following SAH. Using ROC curve analysis, the optimal predictive cutoff for subarachnoid clot burden was determined to be 21 (of a possible 30) on the Hijdra scale (area under the curve 0.63).

Conclusions

A greater subarachnoid clot burden and subdural hematoma are associated with the occurrence of seizures after aneurysm rupture. These findings may help to identify patients at greatest risk for seizures and guide informed decisions regarding the prescription of prophylactic anticonvulsive therapy. Clinical trial registration no.: NCT00111085 (ClinicalTrials.gov).

Abbreviations used in this paper:ACA = anterior cerebral artery; AED = antiepileptic drug; AUC = area under the curve; CONSCIOUS-1 = Clazosentan to Overcome Neurological Ischemia and Infarction Occurring after Subarachnoid Hemorrhage; ICA = internal carotid artery; MCA = middle cerebral artery; ROC = receiver operating characteristic; SAH = subarachnoid hemorrhage; WFNS = World Federation of Neurosurgical Societies.

Article Information

Address correspondence to: R. Loch Macdonald, M.D., Ph.D., St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, Canada M5B 1W8. email: MacdonaldLo@smh.ca.

Please include this information when citing this paper: published online April 12, 2013; DOI: 10.3171/2013.3.JNS122097.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Receiver operating characteristic curve analysis of the Hijdra score. Left: An ROC curve analysis demonstrating an AUC of 0.63, significantly better than chance at identifying patients with posthemorrhagic seizures. Right: Optimal sensitivity and specificity of ROC curve analysis for diagnosis of posthemorrhagic seizures in SAH patients is a Hijdra score of 21 (possible maximum of 30).

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