Background
There is practice heterogeneity in the use, type and duration of prophylactic antiseizure medications (ASM) in patients hospitalized with acute, non-traumatic intracerebral hemorrhage (ICH).
Methods
We conducted a systematic review and meta-analysis assessing ASM primary prophylaxis in adults hospitalized with acute, non-traumatic ICH. The following Population, Intervention, Comparator and Outcome (PICO) questions were assessed: 1) Should ASM versus no ASM be used in patients with acute ICH with no history of clinical or electrographic seizures?; 2) If an ASM is used, should levetiracetam (LEV) or phenytoin/fosphenytoin (PHT/fPHT) be preferentially used?; and 3) If an ASM is used, should a long (> 7 days) versus short (≤ 7 days) duration of prophylaxis be used? The main outcomes assessed were early seizure (≤ 14 days), late seizures (> 14 days), adverse events, mortality, and functional and cognitive outcomes. We utilized Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to generate recommendations.
Results
The initial literature search yielded 1,988 articles, and 15 formed the basis of the recommendations. PICO 1: While there was no significant impact of ASM on the outcomes of early or late seizure or mortality, meta-analyses demonstrated increased adverse events and higher relative risk of poor functional outcomes at 90 days with prophylactic ASM use. PICO 2: We did not detect any significant positive or negative effect of PHT/fPHT compared to LEV for early seizures or adverse events, though point estimates tended to favor LEV. PICO 3: Based on one decision analysis, quality-adjusted-life-years were increased with a shorter duration of ASM prophylaxis.
Conclusions
We suggest avoidance of prophylactic ASM in hospitalized adult patients with acute, non-traumatic ICH (weak recommendation, very low quality of evidence). If used, we suggest LEV over PHT/fPHT (weak recommendation, very low quality of evidence) for a short duration (≤ 7 days, weak recommendation, very low quality of evidence).