From the Guidelines
Intracranial bleeds can present with seizures, with the most recent evidence suggesting that new-onset seizures occur in approximately 2.8-28% of patients with spontaneous intracerebral hemorrhage, particularly within the first 24 hours of the hemorrhage. The risk of seizures is highest with subarachnoid hemorrhage, lobar intracerebral hemorrhage, and hemorrhages that extend to the cerebral cortex. Blood irritates the brain tissue and disrupts normal neuronal activity, triggering abnormal electrical discharges that manifest as seizures. These seizures may be focal or generalized depending on the location and extent of bleeding. Early seizures typically occur within the first 24 hours after the bleed, while late seizures can develop days to weeks later. Other common symptoms of intracranial bleeds include sudden severe headache, altered consciousness, focal neurological deficits, nausea, vomiting, and neck stiffness. Management typically involves rapid neuroimaging (CT or MRI), neurosurgical evaluation, and antiseizure medications such as levetiracetam (Keppra) 500-1000mg twice daily or phenytoin with a loading dose of 15-20mg/kg followed by maintenance dosing, as recommended by the American Heart Association/American Stroke Association 1.
Some key points to consider in the management of intracranial bleeds with seizures include:
- The use of prophylactic antiseizure drugs is of unclear benefit, and their use should be individualized based on the patient's risk factors and clinical presentation 1.
- Continuous electroencephalographic monitoring for at least 24 hours is probably reasonable, particularly in patients with depressed mental status out of proportion to the degree of brain injury 1.
- The relationship among seizures, functional outcomes, and mortality is complex and not well defined, and further research is needed to clarify the optimal approach to managing seizures in patients with intracranial bleeds 1.
- The American Heart Association/American Stroke Association recommends that monitoring and management of patients with an ICH should take place in an intensive care unit setting, and that appropriate antiepileptic therapy should always be used for treatment of clinical seizures in patients with ICH 1.
Overall, the management of intracranial bleeds with seizures requires a multidisciplinary approach, including rapid neuroimaging, neurosurgical evaluation, and antiseizure medications, as well as individualized consideration of the patient's risk factors and clinical presentation.
From the Research
Presentation of Intracranial Bleed
- Intracranial bleed, also known as intracranial hemorrhage (ICH), is defined as bleeding within the intracranial vault and has several subtypes depending on the anatomic location of bleeding 2.
- ICH can be caused by trauma, and in the absence of trauma, spontaneous intraparenchymal hemorrhage is a common cause associated with hypertension when found in deep locations such as the basal ganglia, pons, or caudate nucleus 2.
Seizures in Intracranial Bleed
- Seizures can occur in patients with intracranial bleed, and seizure prophylaxis is often used to prevent seizures in these patients 3, 4, 5, 6.
- Levetiracetam is commonly used for seizure prophylaxis in patients with intracranial hemorrhage (ICH), traumatic brain injury (TBI), supratentorial neurosurgery, and spontaneous subarachnoid hemorrhage (SAH) 5.
- Studies have shown that levetiracetam may be effective in reducing the incidence of seizures in patients with supratentorial neurosurgical diseases, but its efficacy in patients with ICH, TBI, or SAH is still unclear 5.
Treatment of Seizures in Intracranial Bleed
- Levetiracetam and phenytoin are two commonly used antiepileptic drugs for seizure prophylaxis in patients with intracranial bleed 4, 6.
- A study found that levetiracetam may be a reasonable alternative to phenytoin for prophylaxis of early posthemorrhagic seizures in pediatric patients with intracranial hemorrhage 6.
- Another study found that phenytoin reaches therapeutic levels in the cerebrospinal fluid (CSF) quickly and is effective in preventing post-traumatic seizures, but levetiracetam does not reach levels needed for seizure prophylaxis in human CSF when loaded at standard dosing regimens in the acute setting 4.