Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, and Department of Surgery, University of Toronto, Ontario, Canada
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.
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.
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).
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.
BedersonJBConnollyESJrBatjerHHDaceyRGDionJEDiringerMN: Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke40:994–10252009
ConnollyESJrRabinsteinAACarhuapomaJRDerdeynCPDionJHigashidaRT: Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke43:1711–17372012
HartYSneadeMBirksJRischmillerJKerrRMolyneuxA: 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. Clinical article. J Neurosurg115:1159–11682011
HohBLNathooSChiYYMoccoJBarkerFGII: Incidence of seizures or epilepsy after clipping or coiling of ruptured and unruptured cerebral aneurysms in the nationwide inpatient sample database: 2002–2007. Neurosurgery69:644–6502011
MolyneuxAJKerrRSYuLMClarkeMSneadeMYarnoldJA: International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet366:809–8172005
TeasdaleGMDrakeCGHuntWKassellNSanoKPertuisetB: A universal subarachnoid hemorrhage scale: report of a committee of the World Federation of Neurosurgical Societies. J Neurol Neurosurg Psychiatry51:14571988