Vivek Rai, MD
Seizures are a common complication of acute intracerebral hemorrhage (ICH). Further, based on timing of first symptomatic event, seizures are categorized into early (occurring within first 7 days of ICH) and late seizures (occurring after first 7 days of ICH). While early seizures (ES) are thought to result from acute disruption of brain integrity and function, late seizures (LS) are believed to occur due to neuronal reorganization and formation of new epileptogenic foci. Although a number of studies have looked at the relationship between ES and LS, no tools or risk stratification systems are available to predict LS.
Haapaniemi and colleagues analyzed data of about 1000 patients of primary ICH through Helsinki University Central Hospital, Finland, excluding patients with ICH due to tumor, trauma, subarachnoid hemorrhage (SAH) and ischemic stroke. The authors report 11% incidence of ES and 9.2% incidence of LS which is in line with other reported data. Of the several variables, cortical involvement, younger age (<65 y), larger ICH volume at baseline (>10 mL), and early seizures within 7 days of ICH were associated with development of LS, with coefficients ranging from 0.8 to 1.5 which were rounded to 1 to generate CAVE score ranging from 0-4. The corresponding risk of LS during follow-up was 0.6%, 3.6%, 9.8%, 34.8%, and 46.2% for CAVE score points 0 to 4, respectively. The scoring system was validated in a smaller PITCH cohort based in Lille, France.
The authors have developed a novel risk stratification scoring system which is easy to remember and calculate. Further, they have provided evidence of validation of the proposed CAVE score in a smaller but unrelated cohort. The CAVE score can be of great clinical utility in identification of patients who are at high risk of developing epilepsy after ICH. I only wish that the authors had included tumor, trauma and SAH patients in their analysis to further broaden the application of this tool. Further investigations are necessary to study the use of CAVE score in making clinical decisions about treatment with anti-epileptic medications.