Peggy Nguyen, MD
The most recent AHA/ASA guidelines recommend against the use of routine antiepileptic prophylaxis in patients with intracerebral hemorrhage due to studies suggesting AED use in ICH patients lead to more functional and cognitive dysfunction; however, these studies were done primarily with the use of older antiepiletics such as phenytoin.

Here, the authors identified a subgroup of consecutive patients (n=744) in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study enrolled between 10/13/2010 and 10/30/2012, who were not already on antiepileptics at presentation and did not have a seizure on presentation in order to characterize outcomes of those who received AED prophylaxis and those who did not. Of the 744 patients, 39% received an antiepileptic for prophylaxis, of which 89% received leviteracetam. In addition to racial and ethnic differences in the baseline characteristics among patients, there were also important differences between those who received AED prophylaxis and those who did not; namely, (1) AED use was more frequent in those with larger hematomas and lobar hemorrhages. Craniotomies were more common in patients who received AEDs but this was not significantly associated on stepwise regression. Prophylactic AED use was associated with worse outcomes on the unadjusted model for 3-month outcomes, but after adjusting for GCS, age, race/ethnicity, sex, hematoma volume, presence of IH, and craniotomy, prophylactic AED use was no longer associated with 3-month outcome.

This suggests that the association of poor outcomes associated with AED prophylaxis in ICH may be erroneously attributed to the AED, when it may actually be a function of the larger hematoma volumes and ICH characteristics of the population receiving AEDs. In addition, with leviteracetam being prescribed more often in lieu of the older antiepileptics, a poor outcome which may have been associated with the older antiepileptics might no longer be sufficient reason to recommend against the use of AED prophylaxis in the ICH population. The AHA/ASA recommendation is cautious, to be certain, but it may be time to revisit this issue, and a larger study may be warranted.