The indications for seizure prophylaxis and their management in the setting of ICH are controversial. The reported incidence of seizures and status epilepticus in ICH varies. A large prospective study noted a 10% incidence of seizures in all patients with ICH (52). An expect-edly higher incidence was reported in patients with lobar or extensive ICH (53,54 ), and another study documented seizure activity in 14% of patients with lobar ICH and in only 4% in patients with deep ICH (55). Additional information favoring the use of seizure prophylaxis derives from a report by investigators who noted an incidence of seizures in 21% of patients with subcortical hemorrhages, as well as seizure association with increased midline shift (56). In its guidelines, the AHA Stroke Council recommended uniform seizure prophylaxis in the acute period after ICH and SAH (2). These guidelines also suggest the dose of phenytoin to be titrated to serum levels of 14 to 23 |g/mL; the discontinuation of prophylaxis after one month is also recommended (57 ).

Patients who develop seizures after 2 weeks from ictus appear to be at a higher risk of developing epilepsy, and treatment is continued for more than a month (58 ). The follow-up of these patients might require assessment every 6 months for their need of anticonvulsants (59 ).

Although concerns about use of anticonvulsant medication in the absence of clear seizure activity are valid (60), the incidence of unrecognized nonconvulsive seizures in obtunded ICH patients supports the use of short-term prophylaxis in these high-risk patients (61,62). An electroencephalogram (EEG) is imperative in patients who are obtunded or have a fluctuating mental status. Preferably, continuous 24-hour EEG monitoring should be obtained.

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