Guidelines for Seizure Prophylaxis in Patients with Aneurysmal Subarachnoid Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society.
A Shaun Rowe, Sahar F Zafar, Eljim Tesoro et al.
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In 30 seconds
This systematic review and meta-analysis informed Neurocritical Care Society guidance on antiseizure medication (ASM) prophylaxis in adults hospitalized with aneurysmal subarachnoid hemorrhage (SAH) and without prior clinical or electrographic seizures. Ten articles underpinned the recommendations. ASM versus no ASM showed no significant differences in early seizures, adverse events, mortality, or functional outcomes. Comparisons of phenytoin/fosphenytoin with levetiracetam suggested different potential benefits, but evidence certainty was low. Overall, the authors judged the evidence insufficient for strong recommendations and issued conditional guidance on whether to use prophylaxis, drug choice, and duration.
Key findings
- Across 10 included articles, ASM versus no ASM showed no significant difference in early seizures, adverse events, mortality, or functional outcomes.
- Phenytoin/fosphenytoin was associated with fewer early seizures, while levetiracetam was associated with lower risk of neurologic decline; evidence certainty was low.
- Extended ASM use may be associated with lower seizure risk but higher risk of adverse effects.
Why it matters
Seizure prophylaxis after aneurysmal SAH varies in practice, and this review finds no clear overall outcome advantage for routine ASM over no ASM. The findings also highlight a potential trade-off between seizure prevention and adverse effects with longer use. Recognising the low certainty of much of the evidence helps frame these decisions without overstating comparative benefits.
What to keep in mind
The evidence base was limited to 10 articles, and the authors rated overall evidence quality as low, precluding strong recommendations.