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Lekoubou A, Cohrs A, Dejuk M, Hong J, Sen S, Bonilha L, Chinchilli VM. Acute seizures after spontaneous intracerebral hemorrhage in young individuals: 11-year trends and association with mortality. Epilepsy Res 2024; 205:107408. [PMID: 39002389 DOI: 10.1016/j.eplepsyres.2024.107408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/27/2024] [Accepted: 07/01/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND The rate of spontaneous Intracerebral Hemorrhage (sICH) is rising among young Americans. Trends in acute seizure (AS) incidence in this age group is largely unknown. Further, the association of AS with mortality has not been reported in this age group. The aim of this study is to determine trends in AS among young individuals with sICH. METHODS The Merative MarketScan® Commercial Claims and Encounters database, for the years 2005 through 2015, served as the data source for this retrospective in-hospital population study. This period was chosen as spontaneous ICH incidence increased among young individuals between 2005 and 2015. Our study population included patients aged 18-64 years with ICH identified using the International Classification of Diseases, Ninth and Tenth Revision (ICD-9/10) codes 430, 431, 432.0, 432.1, 432.9, I61, I61.0, I61.1, I61.2, I61.3, I61.4, I61.5, I61.6, I61.8, and I61.9, excluding those with a prior diagnosis of seizures (ICD-9/10 codes 345.x,780.3x, G40, G41, and R56.8). We computed yearly AS incidence, mortality (in patients with and without seizures), and analyzed trends. We applied a logistic regression model to determine the independent association of AS with mortality accounting for demographic and clinical variables. RESULTS AS incidence increased linearly between 2005 (incidence rate: 8.1 %) and 2015 (incidence rate: 11.0 %), which represents a 26 % relative increase (P for trends <0.0001). In-hospital mortality rate was 14.3 % among those who developed AS and 11.5 % among those who did not have AS. Overall, between 2005 and 2015, in-hospital mortality decreased from 13.0 % to 9.7 % among patients without AS but remained unchanged among those with AS. Patients who developed AS were 10 % more likely to die than those who did not (OR: 1.10, 95 % confidence interval: 1.02-1.18). CONCLUSIONS Between 2005 and 2015, the incidence of AS increased by nearly 26 % among young Americans with sICH. In-patient mortality remained unchanged among those who developed seizures but declined among those who did not. The occurrence of AS was independently associated with a 10 % higher risk of in-hospital death.
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Affiliation(s)
- Alain Lekoubou
- Department of Neurology, Milton S. Hershey Medical Center, Pennsylvania State University, USA; Department of Public Health Sciences, Pennsylvania State University, USA.
| | - Austin Cohrs
- Department of Public Health Sciences, Pennsylvania State University, USA.
| | - Mariana Dejuk
- College of Medicine, Penn State University, Hershey, PA, USA.
| | - Jinpyo Hong
- College of Medicine, Penn State University, Hershey, PA, USA.
| | - Souvik Sen
- University of South Carolina, Department of Neurology, USA.
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Zhang M, Liu T. Efficacy and safety of tranexamic acid in acute traumatic brain injury: A meta-analysis of randomized controlled trials. Am J Emerg Med 2024; 80:35-43. [PMID: 38502985 DOI: 10.1016/j.ajem.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/10/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) holds a pivotal role in the therapeutic approach to traumatic conditions. Nevertheless, its precise influence on diminishing mortality and limiting the progression of intracranial hemorrhage (ICH) during the treatment of traumatic brain injury (TBI) remains indeterminate. METHODS PubMed, EMBASE, Cochrane Library, and Web of Science were searched for randomized controlled trials that compared TXA and a placebo in adults with TBI up to September 31, 2023. Two authors independently abstracted the data and assessed the quality of evidence. Additionally, subgroup analyses were performed to assess outcomes with low heterogenety. RESULTS Our search strategy yielded 11,299 patients from 11 studies. The result showed that TXA had no effect on mortality (RR 0.93 [0.86, 1.00], p = 0.06; I2: 0%, p = 0.79), poor clinical outcomes (RR 0.92 [0.78, 1.09], p = 0.34; I2: 0%, p = 0.40), adverse events (RR 0.94 [0.83, 1.07], p = 0.34; I2: 48%, p = 0.10), vascular occlusive events (RR 0.85 [0.68, 1.06], p = 0.16; I2: 32%, p = 0.22), pulmonary embolism (RR 0.76 [0.47, 1.22], p = 0.26; I2: 0%, p = 0.83), seizure (RR 1.11 [0.92, 1.35], p = 0.27; I2: 0%, p = 0.49) and hemorrhagic complications (RR 0.78 [0.55, 1.09], p = 0.14; I2: 0%, p = 0.42). TXA might reduce the rate of hemorrhagic expansion (RR 0.83 [0.70, 0.99], p = 0.03; I2: 18%, p = 0.29) and mean hemorrhage volume (SMD -0.39 [-0.60, -0.18], p <0.001; I2: 44%, p = 0.13).When the time interval from symptom onset to treatment was <3 h, TXA reduced mean hemorrhage volume (SMD -0.51 [-0.81, -0.20], p = 0.001; I2: 0%, p = 0.94). CONCLUSIONS TXA did not elevate the risk of adverse event, however, the lack of reduction in mortality and the poor clinical outcomes constrain the value of clinical application. Early administration of TXA (within 3 h) may significantly decrease the likelihood of ICH growth in patients with TBI.
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Affiliation(s)
- Minzhi Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Tao Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Key Laboratory of Post Neuro-Injury Neuro-Repair and Regeneration in Central NervousSystem, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China.
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Nandan A, Zhou YM, Demoe L, Waheed A, Jain P, Widjaja E. Incidence and risk factors of post-stroke seizures and epilepsy: systematic review and meta-analysis. J Int Med Res 2023; 51:3000605231213231. [PMID: 38008901 PMCID: PMC10683575 DOI: 10.1177/03000605231213231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/23/2023] [Indexed: 11/28/2023] Open
Abstract
OBJECTIVE Due to variability in reports, the aim of this meta-analysis was to evaluate the incidence and risk factors of post-stroke early seizures (ES) and post-stroke epilepsy (PSE). METHODS The MEDLINE, EMBASE and Web of Science databases were searched for post-stroke ES/PSE articles published on any date up to November 2020. Post-stroke ES included seizures occurring within 7 days of stroke, and PSE included at least one unprovoked seizure. Using random effects models, the incidence and risk factors of post-stroke ES and PSE were evaluated. The study was retrospectively registered with INPLASY (INPLASY2023100008). RESULTS Of 128 included studies in total, the incidence of post-stroke ES was 0.07 (95% confidence interval [CI] 0.05, 0.10) and PSE was 0.10 (95% CI 0.08, 0.13). The rates were higher in children than adults. Risk factors for post-stroke ES included hemorrhagic stroke (odds ratio [OR] 2.14, 95% CI 1.44, 3.18), severe strokes (OR 2.68, 95% CI 1.73, 4.14), cortical involvement (OR 3.09, 95% CI 2.11, 4.51) and hemorrhagic transformation (OR 2.70, 95% CI 1.58, 4.60). Risk factors for PSE included severe strokes (OR 4.92, 95% CI 3.43, 7.06), cortical involvement (OR 3.20, 95% CI 2.13, 4.81), anterior circulation infarcts (OR 3.28, 95% CI 1.34, 8.03), hemorrhagic transformation (OR 2.81, 95% CI 1.25, 6.30) and post-stroke ES (OR 7.24, 95% CI 3.73, 14.06). CONCLUSION Understanding the risk factors of post-stroke ES/PSE may identify high-risk individuals who might benefit from prophylactic treatment.
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Affiliation(s)
- Aathmika Nandan
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Canada
| | - Yi Mei Zhou
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Canada
| | - Lindsay Demoe
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Canada
| | - Adnan Waheed
- Division of Neurology, The Hospital for Sick Children, Toronto, Canada
| | - Puneet Jain
- Division of Neurology, The Hospital for Sick Children, Toronto, Canada
| | - Elysa Widjaja
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Canada
- Department of Medical Imaging, Lurie Children’s Hospital of Chicago, Chicago, IL, USA
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Chhabra N, Crepeau AZ, Demaerschalk BM, Knox MG, Freeman WD, Valencia Sanchez C, Marks LA, O’Carroll CB. Does Initiation of Prophylactic Antiseizure Medication Improve Neurological Outcomes in Patients With Acute Intracerebral Hemorrhage?: A Critically Appraised Topic. Neurologist 2023; 28:422-425. [PMID: 37922729 PMCID: PMC10627540 DOI: 10.1097/nrl.0000000000000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
OBJECTIVE The objective of this study was to critically assess current evidence regarding the role of prophylactic antiseizure medication in patients presenting with acute intracerebral hemorrhage (ICH). METHODS The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario with a clinical question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom-line conclusions. Participants included resident neurologists, a medical librarian, and content experts in the fields of epilepsy, stroke neurology, neurohospitalist medicine, and neurocritical care. RESULTS A randomized clinical trial was selected for critical appraisal. The trial assessed whether prophylactic levetiracetam (LEV) use reduced the risk of acute seizures in patients with ICH, as defined by clinical or electrographic seizure, captured by continuous electroencephalogram 72 hours after enrollment. A total of 42 patients were included in the final analysis (19 in the LEV group and 23 in the placebo group). There was a significantly higher occurrence of seizures in the placebo versus LEV group (LEV 16% vs placebo 43%, P = 0.043). There were no differences in functional outcomes between the groups at 3, 6, or 12 months (P > 0.1). CONCLUSIONS The role of prophylactic treatment with antiseizure medication in ICH remains unclear.
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Affiliation(s)
| | | | | | | | - William David Freeman
- Departments of Critical Care Medicine, Neurologic Surgery, and Neurology, Mayo Clinic, Jacksonville, FL
| | | | - Lisa A. Marks
- Department of Library Services, Mayo Clinic, Phoenix, AZ
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Misra S, Kasner SE, Dawson J, Tanaka T, Zhao Y, Zaveri HP, Eldem E, Vazquez J, Silva LS, Mohidat S, Hickman LB, Khan EI, Funaro MC, Nicolo JP, Mazumder R, Yasuda CL, Sunnerhagen KS, Ihara M, Ross JS, Liebeskind DS, Kwan P, Quinn TJ, Engel J, Mishra NK. Outcomes in Patients With Poststroke Seizures: A Systematic Review and Meta-Analysis. JAMA Neurol 2023; 80:1155-1165. [PMID: 37721736 PMCID: PMC10507596 DOI: 10.1001/jamaneurol.2023.3240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/21/2023] [Indexed: 09/19/2023]
Abstract
Importance Published data about the impact of poststroke seizures (PSSs) on the outcomes of patients with stroke are inconsistent and have not been systematically evaluated, to the authors' knowledge. Objective To investigate outcomes in people with PSS compared with people without PSS. Data Sources MEDLINE, Embase, PsycInfo, Cochrane, LILACS, LIPECS, and Web of Science, with years searched from 1951 to January 30, 2023. Study Selection Observational studies that reported PSS outcomes. Data Extraction and Synthesis The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used for abstracting data, and the Joanna Briggs Institute tool was used for risk-of-bias assessment. Data were reported as odds ratio (OR) and standardized mean difference (SMD) with a 95% CI using a random-effects meta-analysis. Publication bias was assessed using funnel plots and the Egger test. Outlier and meta-regression analyses were performed to explore the source of heterogeneity. Data were analyzed from November 2022 to January 2023. Main Outcomes and Measures Measured outcomes were mortality, poor functional outcome (modified Rankin scale [mRS] score 3-6), disability (mean mRS score), recurrent stroke, and dementia at patient follow-up. Results The search yielded 71 eligible articles, including 20 110 patients with PSS and 1 166 085 patients without PSS. Of the participants with PSS, 1967 (9.8%) had early seizures, and 10 605 (52.7%) had late seizures. The risk of bias was high in 5 studies (7.0%), moderate in 35 (49.3%), and low in 31 (43.7%). PSSs were associated with mortality risk (OR, 2.1; 95% CI, 1.8-2.4), poor functional outcome (OR, 2.2; 95% CI, 1.8-2.8), greater disability (SMD, 0.6; 95% CI, 0.4-0.7), and increased dementia risk (OR, 3.1; 95% CI, 1.3-7.7) compared with patients without PSS. In subgroup analyses, early seizures but not late seizures were associated with mortality (OR, 2.4; 95% CI, 1.9-2.9 vs OR, 1.2; 95% CI, 0.8-2.0) and both ischemic and hemorrhagic stroke subtypes were associated with mortality (OR, 2.2; 95% CI, 1.8-2.7 vs OR, 1.4; 95% CI, 1.0-1.8). In addition, early and late seizures (OR, 2.4; 95% CI, 1.6-3.4 vs OR, 2.7; 95% CI, 1.8-4.1) and stroke subtypes were associated with poor outcomes (OR, 2.6; 95% CI, 1.9-3.7 vs OR, 1.9; 95% CI, 1.0-3.6). Conclusions and Relevance Results of this systematic review and meta-analysis suggest that PSSs were associated with significantly increased mortality and severe disability in patients with history of stroke. Unraveling these associations is a high clinical and research priority. Trials of interventions to prevent seizures may be warranted.
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Affiliation(s)
- Shubham Misra
- Division of Stroke & Vascular Neurology, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | | | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland, United Kingdom
| | - Tomotaka Tanaka
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yize Zhao
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Hitten P. Zaveri
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Ece Eldem
- Division of Stroke & Vascular Neurology, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Juan Vazquez
- Albert Einstein College of Medicine, Bronx, New York
| | - Lucas Scárdua Silva
- Department of Neurology, School of Medical Sciences, University of Campinas-UNICAMP, Sao Paulo, Brazil
| | - Saba Mohidat
- The University of Melbourne, Melbourne, Victoria, Australia
| | - L. Brian Hickman
- Department of Neurology, The University of California, Los Angeles
| | - Erum I. Khan
- Division of Stroke & Vascular Neurology, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
- Alzheimer’s Disease Research Center, University of Alabama, Birmingham
| | - Melissa C. Funaro
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, Connecticut
| | - John-Paul Nicolo
- Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | | | - Clarissa Lin Yasuda
- Department of Neurology, School of Medical Sciences, University of Campinas-UNICAMP, Sao Paulo, Brazil
| | | | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Joseph S. Ross
- Section of General Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Patrick Kwan
- The AIM for Health, Faculty of IT, Monash University, Melbourne, Victoria, Australia
| | - Terence J. Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland, United Kingdom
| | - Jerome Engel
- Department of Neurology, The University of California, Los Angeles
| | - Nishant K. Mishra
- Division of Stroke & Vascular Neurology, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
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Pszczolkowski S, Law ZK. Editorial comment on "Development and validation of a novel radiomics-clinical model for predicting post-stroke epilepsy after first-ever intracerebral haemorrhage". Eur Radiol 2023; 33:4524-4525. [PMID: 36977856 DOI: 10.1007/s00330-023-09565-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 02/23/2023] [Accepted: 03/11/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Stefan Pszczolkowski
- Radiological Sciences, Mental Health and Clinical Neuroscience, School of Medicine, Medical School Queens Medical Centre, University of Nottingham, Room A39d, Precision Imaging Beacon A floor, Nottingham, NG7 2UH, UK.
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK.
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK.
| | - Zhe Kang Law
- Department of Medicine, Faculty of Medicine, The National University of Malaysia, Kuala Lumpur, Malaysia
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Liu T, Mai J, Pang L, Huang Y, Han J, Su W, Chen K, Qin P. Effects of subarachnoid extension following intracerebral hemorrhage: A systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e32225. [PMID: 36626509 PMCID: PMC9750540 DOI: 10.1097/md.0000000000032225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The effects of subarachnoid extension (SAHE) following intracerebral hemorrhage (ICH) have not yet been fully understood. We conducted a systematic review and meta-analysis of published literature on this topic to better understand the effects of SAHE. METHODS PubMed, Embase, and Cochrane databases were thoroughly searched from inception to October 16, 2022 to identify studies that evaluated the association between SAHE and mortality and worse functional outcomes in primary ICH. Crude odds ratios (cOR) and adjusted odds ratios (aOR) with 95% confidence interval (CI) were calculated to compare the endpoints. RESULTS Three studies with 3368 participants were eventually included in the analysis. In the short-term follow-up of the primary endpoint, no association was observed between SAHE and mortality (cOR: 0.51, 95% CI: 0.01-28.19; aOR: 2.31, 95% CI: 0.72-7.45). In the long-term follow-up of the primary endpoint, SAHE was associated with a significantly increased mortality of patients with primary ICH (cOR: 3.00, 95% CI: 2.27-3.98); however, only 1 study provided the values of aOR and 95% CI and showed that SAHE was not associated with increased mortality (aOR: 1.14, 95% CI: 0.71-1.83). For the secondary endpoint, the data of only 1 study on major disability (modified Rankin Scale = 3-5) were available, and the results revealed that SAHE increased the probability of major disability, but not after adjusting for baseline hematoma volume. CONCLUSION There is insufficient evidence to demonstrate the correlation between SAHE and mortality and worse functional outcomes in primary ICH. The validation of this correlation requires further studies as the potential effect and mechanisms of SAHE remain unclear.
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Affiliation(s)
- Tingzhi Liu
- Department of Neurology, the Second People’s Hospital of Qinzhou, Qinzhou, Guangxi Zhuang Autonomous Region, China
| | - Jilin Mai
- Department of Neurology, Beihai People’s Hospital, the Ninth Affiliated Hospital of Guangxi Medical University, Beihai, Guangxi Zhuang Autonomous Region, China
| | - Linlin Pang
- Department of Neurology, Minzu Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Ya Huang
- Department of Neurology, the Second People’s Hospital of Qinzhou, Qinzhou, Guangxi Zhuang Autonomous Region, China
| | - Jing Han
- Department of Neurology, the Second People’s Hospital of Qinzhou, Qinzhou, Guangxi Zhuang Autonomous Region, China
| | - Weixiang Su
- Department of Neurology, the Second People’s Hospital of Qinzhou, Qinzhou, Guangxi Zhuang Autonomous Region, China
| | - Kaichang Chen
- Department of Neurology, the Second People’s Hospital of Qinzhou, Qinzhou, Guangxi Zhuang Autonomous Region, China
| | - Peiying Qin
- Department of Neurology, the Second People’s Hospital of Qinzhou, Qinzhou, Guangxi Zhuang Autonomous Region, China
- * Correspondence: Peiying Qin, Department of Neurology, the Second People’s Hospital Medical Group of Qinzhou, Wenfeng South Road, Qinnan District, Qinzhou, 535000, China (e-mail: )
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Seiffge DJ, Polymeris AA, Law ZK, Krishnan K, Zietz A, Thilemann S, Werring D, Al-Shahi Salman R, Dineen RA, Engelter ST, Bath PM, Sprigg N, Lyrer P, Peters N. Cerebral Amyloid Angiopathy and the Risk of Hematoma Expansion. Ann Neurol 2022; 92:921-930. [PMID: 36054211 PMCID: PMC9804369 DOI: 10.1002/ana.26481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE We assessed whether hematoma expansion (HE) and favorable outcome differ according to type of intracerebral hemorrhage (ICH). METHODS Among participants with ICH enrolled in the TICH-2 (Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage) trial, we assessed baseline scans for hematoma location and presence of cerebral amyloid angiopathy (CAA) using computed tomography (CT, simplified Edinburgh criteria) and magnetic resonance imaging (MRI; Boston criteria) and categorized ICH as lobar CAA, lobar non-CAA, and nonlobar. The main outcomes were HE and favorable functional outcome. We constructed multivariate regression models and assessed treatment effects using interaction terms. RESULTS A total of 2,298 out of 2,325 participants were included with available CT (98.8%; median age = 71 years, interquartile range = 60-80 years; 1,014 female). Additional MRI was available in 219 patients (9.5%). Overall, 1,637 participants (71.2%) had nonlobar ICH; the remaining 661 participants (28.8%) had lobar ICH, of whom 202 patients had lobar CAA-ICH (8.8%, 173 participants according to Edinburgh and 29 participants according to Boston criteria) and 459 did not (lobar non-CAA, 20.0%). For HE, we found a significant interaction of lobar CAA ICH with time from onset to randomization (increasing risk with time, pinteraction < 0.001) and baseline ICH volume (constant risk regardless of volume, pinteraction < 0.001) but no association between type of ICH and risk of HE or favorable outcome. Tranexamic acid significantly reduced the risk of HE (adjusted odds ratio = 0.7, 95% confidence interval = 0.6-1.0, p = 0.020) without statistically significant interaction with type of ICH (pinteraction = 0.058). Tranexamic acid was not associated with favorable outcome. INTERPRETATION Risk of HE in patients with lobar CAA-ICH was not independently increased but seems to have different dynamics compared to other types of ICH. The time window for treatment of CAA-ICH to prevent HE may be longer. ANN NEUROL 2022;92:921-930.
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Affiliation(s)
- David J Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Zhe Kang Law
- Stroke Trials Unit, University of Nottingham, Nottingham, UK.,Department of Medicine, National University of Malaysia, Bangi, Malaysia
| | - Kailash Krishnan
- Stroke Trials Unit, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sebastian Thilemann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David Werring
- Stroke Research Centre, University College London Queen Square Institute of Neurology, London, UK
| | | | - Robert A Dineen
- Radiological Sciences, University of Nottingham, Nottingham, UK.,National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham, UK
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Hospital for Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Hospital for Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland.,Stroke Center, Hirslanden Clinic, Zürich, Switzerland
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9
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Peter-Derex L, Philippeau F, Garnier P, André-Obadia N, Boulogne S, Catenoix H, Convers P, Mazzola L, Gouttard M, Esteban M, Fontaine J, Mechtouff L, Ong E, Cho TH, Nighoghossian N, Perreton N, Termoz A, Haesebaert J, Schott AM, Rabilloud M, Pivot C, Dhelens C, Filip A, Berthezène Y, Rheims S, Boutitie F, Derex L. Safety and efficacy of prophylactic levetiracetam for prevention of epileptic seizures in the acute phase of intracerebral haemorrhage (PEACH): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Neurol 2022; 21:781-791. [PMID: 35963261 DOI: 10.1016/s1474-4422(22)00235-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/15/2022] [Accepted: 05/24/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND The incidence of early seizures (occurring within 7 days of stroke onset) after intracerebral haemorrhage reaches 30% when subclinical seizures are diagnosed by continuous EEG. Early seizures might be associated with haematoma expansion and worse neurological outcomes. Current guidelines do not recommend prophylactic antiseizure treatment in this setting. We aimed to assess whether prophylactic levetiracetam would reduce the risk of acute seizures in patients with intracerebral haemorrhage. METHODS The double-blind, randomised, placebo-controlled, phase 3 PEACH trial was conducted at three stroke units in France. Patients (aged 18 years or older) who presented with a non-traumatic intracerebral haemorrhage within 24 h after onset were randomly assigned (1:1) to levetiracetam (intravenous 500 mg every 12 h) or matching placebo. Randomisation was done with a web-based system and stratified by centre and National Institutes of Health Stroke Scale (NIHSS) score at baseline. Treatment was continued for 6 weeks. Continuous EEG was started within 24 h after inclusion and recorded over 48 h. The primary endpoint was the occurrence of at least one clinical seizure within 72 h of inclusion or at least one electrographic seizure recorded on continuous EEG, analysed in the modified intention-to-treat population, which comprised all patients who were randomly assigned to treatment and who had a continuous EEG performed. This trial was registered at ClinicalTrials.gov, NCT02631759, and is now closed. Recruitment was prematurely stopped after 48% of the recruitment target was reached due to a low recruitment rate and cessation of funding. FINDINGS Between June 1, 2017, and April 14, 2020, 50 patients with mild-to-moderate severity intracerebral haemorrhage were included: 24 were assigned to levetiracetam and 26 to placebo. During the first 72 h, a clinical or electrographic seizure was observed in three (16%) of 19 patients in the levetiracetam group versus ten (43%) of 23 patients in the placebo group (odds ratio 0·16, 95% CI 0·03-0·94, p=0·043). All seizures in the first 72 h were electrographic seizures only. No difference in depression or anxiety reporting was observed between the groups at 1 month or 3 months. Depression was recorded in three (13%) patients who received levetiracetam versus four (15%) patients who received placebo, and anxiety was reported for two (8%) patients versus one (4%) patient. The most common treatment-emergent adverse events in the levetiracetam group versus the placebo group were headache (nine [39%] vs six [24%]), pain (three [13%] vs ten [40%]), and falls (seven [30%] vs four [16%]). The most frequent serious adverse events were neurological deterioration due to the intracerebral haemorrhage (one [4%] vs four [16%]) and severe pneumonia (two [9%] vs two [8%]). No treatment-related death was reported in either group. INTERPRETATION Levetiracetam might be effective in preventing acute seizures in intracerebral haemorrhage. Larger studies are needed to determine whether seizure prophylaxis improves functional outcome in patients with intracerebral haemorrhage. FUNDING French Ministry of Health.
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Affiliation(s)
- Laure Peter-Derex
- Centre for Sleep Medicine and Respiratory Diseases, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France; Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France.
| | - Frédéric Philippeau
- Stroke Unit, Department of Neurology, Fleyriat Hospital, Bourg en Bresse, France
| | - Pierre Garnier
- Stroke Centre, Department of Neurology, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Nathalie André-Obadia
- Department of Functional Neurology and Epileptology, Lyon University Hospital, Lyon, France; Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France
| | - Sébastien Boulogne
- Department of Functional Neurology and Epileptology, Lyon University Hospital, Lyon, France; Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France
| | - Hélène Catenoix
- Department of Functional Neurology and Epileptology, Lyon University Hospital, Lyon, France; Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France
| | - Philippe Convers
- Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France; Clinical Neurophysiology Unit, Department of Neurology, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Laure Mazzola
- Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France; Clinical Neurophysiology Unit, Department of Neurology, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Michel Gouttard
- Stroke Unit, Department of Neurology, Fleyriat Hospital, Bourg en Bresse, France
| | - Maud Esteban
- Stroke Centre, Lyon University Hospital, Lyon, France
| | | | | | - Elodie Ong
- Stroke Centre, Lyon University Hospital, Lyon, France
| | - Tae-Hee Cho
- Stroke Centre, Lyon University Hospital, Lyon, France
| | | | - Nathalie Perreton
- Public Health Unit, Clinical Research and Epidemiology Department, Lyon University Hospital, Lyon, France; University Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Anne Termoz
- Public Health Unit, Clinical Research and Epidemiology Department, Lyon University Hospital, Lyon, France; University Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Julie Haesebaert
- Public Health Unit, Clinical Research and Epidemiology Department, Lyon University Hospital, Lyon, France; University Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Anne-Marie Schott
- Public Health Unit, Clinical Research and Epidemiology Department, Lyon University Hospital, Lyon, France; University Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Muriel Rabilloud
- Department of Biostatistics, Lyon University Hospital, Lyon, France; Biometry and Evolutionary Biology Laboratory, CNRS UMR 5558, Biostatistics Health Team, Villeurbanne, France
| | - Christine Pivot
- Pharmacy, FRIPHARM, Edouard Herriot Hospital, Lyon University Hospital, Lyon, France
| | - Carole Dhelens
- Pharmacy, FRIPHARM, Edouard Herriot Hospital, Lyon University Hospital, Lyon, France
| | - Andrea Filip
- Department of Neuroradiology, Neurological Hospital, Lyon University Hospital, Lyon, France
| | - Yves Berthezène
- Department of Neuroradiology, Neurological Hospital, Lyon University Hospital, Lyon, France
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Lyon University Hospital, Lyon, France; Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France
| | - Florent Boutitie
- Department of Biostatistics, Lyon University Hospital, Lyon, France; Biometry and Evolutionary Biology Laboratory, CNRS UMR 5558, Biostatistics Health Team, Villeurbanne, France
| | - Laurent Derex
- Stroke Centre, Lyon University Hospital, Lyon, France; University Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
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Seizure prevention in patients with intracerebral haemorrhage. Lancet Neurol 2022; 21:760-761. [DOI: 10.1016/s1474-4422(22)00297-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 11/15/2022]
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11
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Lin HY, Wei QQ, Huang JY, Pan XH, Liang NC, Huang CX, Long T, Gao W, Shi SL. Relationship Between Mortality and Seizures After Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis. Front Neurol 2022; 13:922677. [PMID: 35795802 PMCID: PMC9251061 DOI: 10.3389/fneur.2022.922677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background The relationship between mortality and seizures after intracerebral hemorrhage (ICH) has not yet been understood until now. A meta-analysis was performed to assess the effect of post-ICH seizures on mortality among patients with ICH. Methods PubMed and Embase were searched from the establishment of the databases to December 2021 to identify literature that evaluated the relationship between post-ICH seizures and mortality in ICH. Crude odds ratios and adjusted odds ratios with a 95% confidence interval (CI) were pooled using a random-effects model. Results Thirteen studies involving 245,908 participants were eventually included for analysis. The pooled estimate suggested that post-ICH seizures were not associated with significantly increased mortality in patients with ICH (crude odds ratios 1.35, 95% CI: 0.91–2; adjusted adds ratios 1.22, 95% CI: 0.78–1.88). However, the relationship was not consistent in subgroup analysis or robust in a sensitivity analysis. Conclusions This meta-analysis proved that post-ICH seizures were not associated with significantly increased mortality in patients with ICH. However, this result could be influenced by confounding factors, so more high-quality research is needed.
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Affiliation(s)
- Hong-yu Lin
- Department of Neurology, People's Hospital of Chongzuo City, Chongzuo, China
| | - Qing-qing Wei
- Department of Neurology, People's Hospital of Chongzuo City, Chongzuo, China
| | - Jian-yi Huang
- Department of Neurology, People's Hospital of Chongzuo City, Chongzuo, China
| | - Xing-hua Pan
- Department of Neurology, People's Hospital of Chongzuo City, Chongzuo, China
| | - Ning-chao Liang
- Department of Neurology, People's Hospital of Chongzuo City, Chongzuo, China
| | - Cai-xia Huang
- Department of Neurology, People's Hospital of Chongzuo City, Chongzuo, China
- *Correspondence: Cai-xia Huang
| | - Teng Long
- Department of Neurology, People's Hospital of Chongzuo City, Chongzuo, China
| | - Wen Gao
- Department of Neurology, People's Hospital of Liuzhou City, Liuzhou, China
| | - Sheng-liang Shi
- Department of Neurology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
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12
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Derex L, Rheims S, Peter-Derex L. Seizures and epilepsy after intracerebral hemorrhage: an update. J Neurol 2021; 268:2605-2615. [PMID: 33569652 DOI: 10.1007/s00415-021-10439-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/30/2021] [Indexed: 02/05/2023]
Abstract
Seizures are common after intracerebral hemorrhage, occurring in 6-15% of the patients, mostly in the first 72 h. Their incidence reaches 30% when subclinical or non-convulsive seizures are diagnosed by continuous electroencephalogram. Several risk factors for seizures have been described including cortical location of intracerebral hemorrhage, presence of intraventricular hemorrhage, total hemorrhage volume, and history of alcohol abuse. Seizures after intracerebral hemorrhage may theoretically be harmful as they can lead to sudden blood pressure fluctuations, increased intracranial pressure, and neuronal injury due to increased metabolic demand. Some recent studies suggest that acute symptomatic seizures (occurring within 7 days of stroke) are associated with worse functional outcome and increased risk of death despite accounting for other known prognostic factors such as age and baseline hemorrhage volume. However, the impact of seizures on prognosis is still debated and it remains unclear if treating or preventing seizures might lead to improved clinical outcome. Thus, the currently available scientific evidence does not support the routine use of antiseizure medication as primary prevention among patients with intracerebral hemorrhage. Only prospective adequately powered randomized-controlled trials will be able to answer whether seizure prophylaxis in the acute or longer term settings is beneficial or not in patients with intracerebral hemorrhage.
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Affiliation(s)
- Laurent Derex
- Stroke Center, Department of Neurology, Neurological Hospital, Hospices Civils de Lyon, University of Lyon, 59 boulevard Pinel, 69677, Bron cedex, France.
- Research On Healthcare Performance (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, Lyon, France.
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon, University of Lyon, Lyon, France
- Lyon 1 University, Lyon, France
- INSERM U1028-CNRS UMR 5292, Lyon Neuroscience Research Center, Lyon, France
| | - Laure Peter-Derex
- Lyon 1 University, Lyon, France.
- INSERM U1028-CNRS UMR 5292, Lyon Neuroscience Research Center, Lyon, France.
- Center for Sleep Medicine and Respiratory Diseases, Croix-Rousse Hospital, Hospices Civils de Lyon, University of Lyon, 103 Grande rue de la Croix-Rousse, 69004, Lyon, France.
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