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.

中文翻译：

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自发性脑内和蛛网膜下腔出血中预防性抗惊厥药的使用模式：从业者调查结果

背景

自发性脑出血 (sICH) 和动脉瘤性蛛网膜下腔出血 (aSAH) 患者的预防性抗癫痫药物 (ASM) 的使用存在争议。

客观的

本次调查的目的是更好地描述北美 sICH 和 aSAH 中预防性 ASM 使用的现状。

方法

使用电子调查工具对对神经血管疾病管理感兴趣或具有专业知识的美国和加拿大神经外科医生、神经科医生和介入神经放射科医生进行了调查。

结果

发送了 794 个调查请求；收到了 103 份 (13%) 的回复。大多数受访者是神经外科医生（84%）。38% 的受访者自称是血管神经外科医生，10% 的受访者自称是神经重症监护专家。72% 的人从事学术实践。当被问及他们对 ASM 预防（aSAH、sICH 或两者）的偏好时，最常见的回答是在 aSAH 和 sICH 中都使用预防（43%，45%）。21 人 (22%) 未使用常规预防措施，而 22 人 (23%) 仅在 aSAH 中使用预防，9 人 (9%) 仅在 sICH 中使用。大多数回答说他们在 sICH 中使用 ASM 预防的从业者 (35, 67%) 选择性地使用了 ASM。对于 aSAH，绝大多数 (53, 82%) 对所有患者进行了预防。受访者认为，如果 sICH 位于皮质部位、幕上部位或与结构异常相关（例如肿瘤、动静脉畸形），他们更有可能对 sICH 患者使用 ASM 左乙拉西坦 (Keppra) 是最常用的 ASM (73, 99%)。当被问及“当前 AHA/ASA 指南建议不要在自发性 ICH 中使用预防性抗惊厥药”这一说法是对还是错时，78 人 (83%) 正确回答该建议是正确的。只有 24 位受访者回答了他们是否愿意将 sICH 和/或 aSAH 患者随机分组，接受或不接受 ASM 预防的管理。其中，13 人 (54%) 表示愿意随机分配 sICH 患者，而只有 6 人 (25%) 愿意随机分配 aSAH 患者。

结论

尽管缺乏任何具体的循证指南来支持这种做法，但在 sICH 和 aSAH 后使用 ASM 预防癫痫发作仍然很普遍。需要一项大规模随机对照试验来明确自发性颅内出血患者预防性 ASM 使用的实践。