Seizure Prophylaxis After Spontaneous Intracerebral Hemorrhage

Abstract

Importance: There is limited evidence concerning optimal seizure prophylaxis after spontaneous intracerebral hemorrhage (sICH). Objective: To evaluate which of four seizure prophylaxis strategies provides the greatest net benefit for sICH patients. Design, Setting, and Participants: Decision model simulating four common scenarios: 1) 60-year-old male with low early- (≤ 7 days post-stroke) (10%) and late-seizure risks (3.6% or 9.8%), and average short- and long-term adverse drug reaction (ADR) risks (9% and 30%, respectively); 2) 80-year-old female with low early- (10%) and late-seizure risks (3.6% or 9.8%), and high short- and long-term ADR risks (24% and 80%); 3) 55-year-old male with high early- (19%) and late-seizure risks (34.8% or 46.2%), and low short- and long-term ADR risks (9% and 30%); and 4) 45-year-old female with high early- (19%) and late-seizure risks (34.8% or 46.2%), and high short- and long-term ADR risks (18% and 60%). Interventions: Four antiseizure drug strategies: 1) Conservative: short-term (7-day) secondary early-seizure prophylaxis with long-term therapy after late-seizure; 2) Moderate: long-term secondary early- or late-seizure prophylaxis; 3) Aggressive: long-term primary prophylaxis; 4) Risk-guided: short-term secondary early-seizure prophylaxis among low-risk patients (2HELPS2B score), short-term primary prophylaxis among higher-risk patients, and long-term late-seizure secondary therapy. Main Outcomes and Measures: Quality-adjusted life years (QALYs). Results: For scenario 1, risk-guided strategy was preferred over conservative, moderate, and aggressive (QALYs = 8.13, 8.08, 8.07, and 7.88, respectively). For scenario 2, conservative and risk-guided strategies performed comparably and were favored over moderate and aggressive (QALYs = 2.18, 2.17, 2.09, 1.15). For scenario 3, aggressive strategy was preferred over moderate, risk-guided and conservative (QALY = 9.21, 8.93, 8.98, 8.77). For scenario 4, risk-guided strategy was preferred over conservative, moderate, and aggressive (QALY = 11.53, 11.23, 10.93, 8.08). Sensitivity analyses suggested that short-term strategies are preferred under most scenarios, and the risk-guided strategy performs comparably or better than alternative strategies in most settings. Conclusions and Relevance: Our model indicates that short-term (7-day) prophylaxis dominates longer-term therapy following sICH. Implementation of the 2HELPS2B score to guide clinical decisions for initiation of short-term primary versus secondary early-seizure prophylaxis should be considered for all patients after sICH.