Seizure Management in Intracerebral Hemorrhage

Introduction to Seizure Prophylaxis

The American Heart Association/American Stroke Association recommends that prophylactic antiseizure medications should not be routinely administered to patients with intracerebral hemorrhage, as they do not prevent seizures and are associated with worse functional outcomes and increased adverse events 1, 2, 3

Meta-analyses demonstrate that seizure prophylaxis does not prevent early or late seizures in ICH patients, according to the American Heart Association/American Stroke Association 1, 2, 3
Earlier studies with phenytoin showed worse outcomes, and while levetiracetam has a better safety profile, it still does not demonstrate clear benefit for prophylaxis, as stated by the American Heart Association/American Stroke Association 1, 2, 3

Antiseizure medications should be initiated only when clinical or electrographic seizures are documented and suspected to contribute to impaired consciousness, as recommended by the American Heart Association/American Stroke Association 1, 2, 3
Clinical or electrographic seizures contributing to altered mental status should be treated with antiseizure medications, according to the American Heart Association/American Stroke Association and other guidelines 1, 2, 3, 4

Patients with impaired or fluctuating level of consciousness out of proportion to the degree of brain injury or metabolic abnormalities should undergo EEG monitoring, as recommended by the American Heart Association/American Stroke Association 1, 2, 3
Continuous EEG monitoring for at least 24-48 hours is reasonable when seizures are clinically suspected, as 28% of electrographic seizures are detected after 24 hours, and 94% by 48 hours, according to the American Heart Association/American Stroke Association 1, 2

Levetiracetam is preferred over phenytoin/fosphenytoin due to better tolerability and fewer adverse effects, as recommended by the American Heart Association/American Stroke Association and other guidelines 4
Phenytoin/fosphenytoin should be avoided as they are associated with worse outcomes in ICH, according to the American Heart Association/American Stroke Association and other guidelines 1, 2, 3, 5

Cortical involvement is a high-risk feature for seizures, as stated by the International Journal of Stroke and other guidelines 4, 6, 5

Risk scores should not be used to justify continuation of prophylactic antiseizure drugs beyond 7 days, as there is no evidence they prevent late seizures, according to the American Heart Association/American Stroke Association 1, 2, 3
Early seizures should not be assumed to worsen outcomes, as prospective studies show early seizures are not independently associated with worse neurological outcomes or mortality, as stated by the International Journal of Stroke and other guidelines 4, 6, 5

The American Heart Association recommends treating continuous focal seizures immediately with antiseizure medication, specifically levetiracetam, due to its better tolerability and fewer adverse effects in ICH patients 7, 8
The American Academy of Neurology suggests avoiding phenytoin/fosphenytoin entirely, as earlier studies demonstrated these agents are associated with increased death and disability in ICH patients 7, 9, 8

The American Heart Association recommends maintaining systolic blood pressure between 130-150 mmHg using short-acting, titratable IV agents to avoid hypotension that worsens cerebral perfusion pressure in the setting of elevated ICP 10
The American Stroke Association advises against aggressive BP reduction below 130 mmHg systolic, as this may critically reduce cerebral perfusion pressure when ICP is already elevated 10

The Neurocritical Care Society suggests considering ICP monitoring if the patient has moderate to severe ICH with reduced level of consciousness 7, 8

The American Academy of Neurology recommends not continuing prophylactic antiseizure medications beyond the acute treatment period unless recurrent seizures occur, as prophylaxis does not prevent early or late seizures in ICH patients 7, 8
The American Heart Association suggests treating documented seizures only—do not use prophylactic antiseizure medications routinely 7, 8

The American Academy of Neurology advises never using phenytoin or fosphenytoin as they are associated with worse functional outcomes and increased adverse events in ICH patients 7, 9, 8
The American Heart Association recommends avoiding overly aggressive BP lowering (<130 mmHg systolic), which can critically reduce cerebral perfusion pressure 10