In subarachnoid hemorrhage (SAH), seizures are frequent and occur at different time points, likely reflecting heterogeneous pathophysiology. Young patients, those with more severe SAH (by clot burden or presence of severe mental status changes at onset or focal neurologic deficits at any time), those with associated increased cortical irritation (by infarction or presence of underlying hematoma), and patients undergoing craniotomy are at higher risk. Advanced neurophysiologic monitoring allows for seizure burden quantification, identification of subclinical seizures, and interictal patterns as well as neurovascular complications that may have an independent impact on the outcome in this population. Practice regarding seizure prophylaxis varies widely; its institution is often guided by the risk–benefit ratio of seizures and medication side effects. Newer anticonvulsants seem to be equally effective and may have a more favorable profile. However, questions regarding the association of seizures and vasospasm, the therapeutic dosing, timing, and duration of antiepileptic treatment and the impact of seizures and antiepileptics on the outcome remain unanswered. In this review, we provide a broad overview of the work in this area and offer a diagnostic and therapeutic approach based on our own expert opinion.
Department of Neurology, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, U.S.A.
Address correspondence and reprint requests to Carolina B. Maciel, MD, Department of Neurology, Yale New Haven Hospital, Yale School of Medicine, 15 York St, Building LCI, 10th floor, Room 912, New Haven, CT 06520, U.S.A.; e-mail: firstname.lastname@example.org.
E.J.G. is supported by Yale's Center for Clinical Investigation CTSA Grant (ULTR000142), Yale's Claude D. Pepper Older Americans Independence Center (P30AG021342 NIH/NIA), American Brain Foundation, and the National Institute of Health.