JAMA Neurology: After cerebral hemorrhage, which epilepsy prevention method is better?

Acute symptomaticSeizures (early seizures, ≤7 days after stroke ) are a common complication of spontaneous intracerebral hemorrhage (sICH)
.

In the case of epileptic seizure prevention after sICH , the recommendations of the guidelines are inconsistent with current clinical practice, perhaps partly because of the lack of high-quality clinical trials
.

Although potential safety issues have prompted people to recommend against using antiepileptic drugs as the main preventive measure, the literature shows that approximately 40% of American sICH patients receive preventive intravenous drugs before the development of epilepsy
.

Because the risk of seizures is a key factor in determining which patient groups may benefit the most from different prevention strategies, effective tools for predicting the risk of early (such as 2HELPS2Bscore) and late seizures can help doctors make treatment decisions
.

Therefore, Felipe JS Jone and others at Harvard University Massachusetts General Hospital used simulation model and decision analysis, combined with current knowledge, according to the type of treatment (primary and secondary prevention), the time of the event ( Early and late onset) and duration of treatment (1 week [short-term] and indefinite [long-term] treatment), to evaluate the trade-offs related to the 4 treatment strategies
.

These strategies include:
(1) Conservative short-term secondary prevention after early onset and long-term treatment after late onset;
(2) Moderate long-term secondary prevention after early onset or long-term secondary treatment after late onset;
(3) Active the long-term primary prevention
(4) low-risk patients (2HELPS2B risk score) early short-term secondary prevention in post-attack risk guidance, short-term primary prevention of high-risk patients, and after two late onset of long-term treatment
.

The aim is to explore which option is related to the greatest net benefit, measured in expected quality-adjusted life years (QALYs)
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The decision analysis uses the model to simulate the following 4 common situations
.

(2) An 80-year-old woman with early (10%) and late (3.

(3) A 55-year-old man has a high risk of early (19%) and late (34.

(4) A 45-year-old woman has a high risk of early (19%) and late (34.

Intervention measures: including the following 4 anti-epileptic drug strategies
.

Main clinical outcome: Quality-adjusted life years (QALYs)
.

They found:

For Scenario 1, risk guidance strategies (8.

For Scenario 2, conservative strategies (2.
18 QALYs) are more popular than risk guidance (2.
17 QALYs), moderate (2.
09 QALYs) and aggressive (1.
15 QALYs) strategies
.

For Scenario 3, active strategies (9.
21 QALYs) are more popular than risk-guided (8.
98 QALYs), moderate (8.
93 QALYs) and conservative (8.
77 QALYs) strategies
.

For Scenario 4, risk guidance strategies (11.
53 QALYs) are more popular than conservative (11.
23 QALYs), moderate (10.
93 QALYs) and aggressive (8.
08 QALYs) strategies
.

Sensitivity analysis shows that in most cases, short-term strategies (conservative and risk guidance) are the first choice, and in most cases, the performance of risk guidance strategies is equal to or better than alternative strategies
.

This decision analysis model shows that short-term (7-day) preventive measures are dominant in long-term treatment after sICH
.
For all patients after sICH, the 2HELPS2B score should be considered to guide the clinical decision to initiate short-term primary or secondary early-seizure prophylaxis
.

Original source:

Jones FJS, Sanches PR, Smith JR, et al.
Seizure Prophylaxis After Spontaneous Intracerebral Hemorrhage.
JAMA Neurol.
Published online July 26, 2021.
doi:10.
1001/jamaneurol.
2021.
2249