Anticonvulsants

The risks and implications of seizures associated with SAH are not well defined, and the need for and efficacy of routinely administered anticonvulsants following SAH for seizure prophylaxis are yet to be established. A large number of seizure-like episodes are associated with aneurysmal rupture. It is unclear, however, whether these episodes are truly epileptic in origin. In a large prospective study, early seizures were reported to occur in 6% of patients (23). A retrospective review found that the majority of early seizures occurred before medical presentation; in-hospital seizures were rare in patients who were administered prophylactic anticonvulsants (24).

The routine use of prophylactic anticonvulsants during the perioperative period has been evaluated in several studies. Nonrandomized studies of patients who underwent craniotomy indicated a benefit of prophylactic anticonvulsants (25-27); however, the number of patients with SAH in these reports was too small to address the issue. A study of patients who underwent coil embolization of an aneurysm (rather than surgery) reported no periprocedural seizures and a delayed de novo seizure rate of 1.7% (28). Risk factors for seizures after SAH include middle cerebral artery aneurysms (29,30), intraparenchymal hematoma (25,29,31), infarcts (32), and a history of hypertension (33). Noteworthily, a recent study found that phenytoin routinely administered to patients following SAH for seizure prophylaxis was associated with worse neurologic and cognitive outcome (34 ).

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