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Patterns of prophylactic anticonvulsant use in spontaneous intracerebral and subarachnoid hemorrhage: results of a practitioner survey

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Abstract

Background

The use of prophylactic anti-seizure medications (ASMs) in the management of patients with spontaneous intracerebral hemorrhage (sICH) and aneurysmal subarachnoid hemorrhage (aSAH) is controversial.

Objective

The purpose of this survey was to better characterize the current state of prophylactic ASM use in sICH and aSAH in North America.

Methods

US and Canadian neurosurgeons, neurologists, and interventional neuroradiologists with an interest in or expertise in the management of neurovascular disease were surveyed using an electronic survey tool.

Results

Seven hundred ninety-four survey requests were sent; responses were received from 103 (13%). The majority of respondents were neurosurgeons (84%). Thirty-eight percent of respondents self-identified as vascular neurosurgeons and 10% self-identified as neurocritical care specialists. Seventy-two percent were in academic practice. When asked their preference for ASM prophylaxis (aSAH, sICH, or both), the most common response was to use prophylaxis in both aSAH and sICH (43, 45%). Twenty-one (22%) did not use routine prophylaxis, while 22 (23%) used prophylaxis only in aSAH and 9 (9%) only in sICH. The majority of practitioners (35, 67%) who answered that they used ASM prophylaxis in sICH, used ASMs selectively. For aSAH, the vast majority (53, 82%) used prophylaxis for all patients. Respondents felt that they were more likely to use ASMs for sICH patients if the sICH was in a cortical location, supratentorial location, or was related to a structural abnormality (e.g., tumor, arteriovenous malformation) Levetiracetam (Keppra) was the most commonly used ASM (73, 99%). When asked whether the statement “Current AHA/ASA Guidelines recommend against the use of prophylactic anticonvulsants in spontaneous ICH” was true or false, 78 (83%) responded correctly that the recommendation is true. Only 24 respondents answered the question as to whether they would be willing to randomize sICH and/or aSAH patients to management with or without ASM prophylaxis. Of these, 13 (54%) said they would be willing to randomize sICH patients, while only 6 (25%) were willing to randomize aSAH patients. There were no statistically significant differences in responses to survey questions when analyzed by practice type (academic versus non-academic) or physician specialty (critical care versus non-critical care, or vascular neurology/neurosurgery versus other).

Conclusion

The use of ASMs for seizure prophylaxis after sICH and aSAH remains widespread despite the lack of any specific evidence-based guideline to support the practice. A large-scale randomized controlled trial is needed to add clarity to the practice of prophylactic ASM use in patients with spontaneous intracranial hemorrhage.

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Acknowledgements

The authors wish to thank Sara Langan for her assistance in the preparation of this manuscript.

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Authors and Affiliations

  1. Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Health Milton S. Hershey Medical Center, 30 Hope Drive, EC110, Hershey, PA, 17033, USA

    Michael J. Gigliotti & Kevin M. Cockroft

  2. Penn State Neuroscience Institute, Penn State M.S. Hershey Medical Center, Hershey, PA, USA

    Shwetha Srikanth & Kevin M. Cockroft

  3. Department of Radiology, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA

    Kevin M. Cockroft

  4. Department of Public Health Sciences, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA

    Kevin M. Cockroft

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  1. Michael J. Gigliotti
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  2. Shwetha Srikanth
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  3. Kevin M. Cockroft
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Correspondence to Kevin M. Cockroft.

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The authors declare no competing interests.

Ethical approval

Our institution’s Human Subjects Protection Office determined that this project did not require formal institutional review board (IRB) review because the study met the criteria for exempt research according to the policies of our institution and the provisions of applicable federal regulations (IRB 00,014,015).

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Gigliotti, M.J., Srikanth, S. & Cockroft, K.M. Patterns of prophylactic anticonvulsant use in spontaneous intracerebral and subarachnoid hemorrhage: results of a practitioner survey. Neurol Sci 43, 1873–1877 (2022). https://doi.org/10.1007/s10072-021-05588-2

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  • DOI: https://doi.org/10.1007/s10072-021-05588-2

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