Seizure Prevention in Aneurysmal Subarachnoid Hemorrhage with Intracerebral Hemorrhage or Other High-Risk Features

This protocol applies to patients with aneurysmal subarachnoid hemorrhage (aSAH) who have not had a seizure but present with one or more features that markedly elevate seizure risk.

Clinical Scenario & High-Risk Features

High-seizure-risk features in aSAH include:

Intracerebral hemorrhage
Ruptured middle cerebral artery aneurysm
High-grade subarachnoid hemorrhage
Hydrocephalus
Cortical infarction

When any of these features accompany aSAH in the absence of active seizures, a proactive seizure prevention strategy is warranted.

Clinical Goal

Prevention of seizures

Treatment Approach (partial overview)

Prophylactic antiseizure medication may be reasonable in this setting — however, not all agents in this class are appropriate, as specific medications are associated with excess morbidity and mortality in aSAH and must be avoided.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1161/str.0000000000000436

In patients with aSAH and high-seizure-risk features (ie, ruptured MCA aneurysm, high-grade SAH, ICH, hydrocephalus, and cortical infarction), use of prophylactic antiseizure medication(s) may be reasonable to prevent seizures.

In patients with aSAH, phenytoin for seizure prevention and/or antiseizure prophylaxis is associated with excess morbidity and mortality.

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