A Randomized Trial of Brief Versus Extended Seizure Prophylaxis After Aneurysmal Subarachnoid Hemorrhage

Human, Theresa; Diringer, Michael N.; Allen, Michelle; Zipfel, Gregory J.; Chicoine, Michael R.; Dacey, Ralph G.; Dhar, Rajat

doi:10.1007/s12028-017-0440-5

Cited by 32 publications

(15 citation statements)

References 15 publications

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“…Increasing interest in using levetiracetam for seizure prophylaxis after TBI and SAH, as well as treatment of status epilepticus, has led to extensive use of levetiracetam in patients with ARC. [60][61][62] Levetiracetam undergoes partial hydrolysis in the serum, with nearly all of the hydrolyzed fraction and the remaining unchanged fraction (~70-80% of the dose) eliminated renally. Levetiracetam clearance correlated modestly well with estimated Cl cr in a neurocritical care cohort (r 2 = 0.527, p=0.01).…”

Section: Dosing Considerationsmentioning

confidence: 99%

Augmented Renal Clearance

2019

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Augmented renal clearance (ARC) is a phenomenon in critically ill patients characterized by increased creatinine clearance and elimination of renally eliminated medications. Patients with severe neurologic injury, sepsis, trauma, and burns have been consistently identified as at risk of ARC, with mean creatinine clearances ranging from 170 ml/minute to more than 300 ml/minute. Several potential mechanisms may contribute to the occurrence of ARC including endogenous responses to increased metabolism and solute production, alterations in neurohormonal balance, and therapeutic maneuvers such as fluid resuscitation. Augmented renal clearance is associated with suboptimal exposure to critical medications, including β‐lactams and vancomycin, increasing the risk of treatment failure. Although definitive screening tools are not yet known, critical care pharmacists must be vigilant in recognizing when ARC may be a contributing factor affecting expected treatment outcomes in individual patients. Optimizing dosing strategies in critically ill patients with ARC remains a goal of continued research. The current review discusses the clinical characteristics and methods of identifying patients at risk of ARC, potential mechanisms for ARC, and describes pharmacotherapy dosing considerations in patients with ARC.

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Section: Dosing Considerationsmentioning

confidence: 99%

Augmented Renal Clearance

2019

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“…114 A second study in patients with aSAH evaluated open label levetiracetam for seizure prophylaxis for either 3 days or until hospital discharge and showed no difference in the incidence of seizures but worse neurological outcomes in the group that received a prolonged duration of therapy. 115 Additional data on phenytoin in this scenario suggest an association with worsened longterm cognitive outcomes, as well as a drug interaction with nimodipine, making it a less than ideal agent for prophylaxis in this patient population. [116][117][118] Current guidelines suggest that the use of a prophylactic antiseizure drug may be considered in the immediate posthemorrhagic period, but therapy should not exceed 7 days and phenytoin should be avoided.…”

Section: Neurological Injurymentioning

confidence: 97%

Principles of Pharmacotherapy of Seizures and Status Epilepticus

2020

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Status epilepticus is a neurological emergency with an outcome that is highly associated with the initial pharmacotherapy management that must be administered in a timely fashion. Beyond first-line therapy of status epilepticus, treatment is not guided by robust evidence. Optimal pharmacotherapy selection for individual patients is essential in the management of seizures and status epilepticus with careful evaluation of pharmacokinetic and pharmacodynamic factors. With the addition of newer antiseizure agents to the market, understanding their role in the management of status epilepticus is critical. Etiology-guided therapy should be considered in certain patients with drug-induced seizures, alcohol withdrawal, or autoimmune encephalitis. Some patient populations warrant special consideration, such as pediatric, pregnant, elderly, and the critically ill. Seizure prophylaxis is indicated in select patients with acute neurological injury and should be limited to the acute postinjury period.

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“…In a systematic review by Lanzino et al, a 3-day seizure prophylaxis regimen was found to provide sufficient control for post-operative seizures, and they related the worse outcome associated with AEDs to phenytoin (28). Other recent studies also emphasize brief courses of 3 to 7 days of prophylaxis and save the extended prophylaxis for those with mentioned risk factors (14,29). From March 2016, we have switched to a 1-week course of phenytoin or levetiracetam and the results were promising so far for seizure control (13).…”

Section: Future Perspectivementioning

confidence: 99%

Long-Versus Short-Term Seizure Prophylaxis After Craniotomy for Clipping in Aneurysmal Subarachnoid Hemorrhage; A Retrospective Cohort Study

et al. 2019

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Background: Seizures are quite common following subarachnoid hemorrhage (SAH) and due to increased mortality and morbidity in this setting, thus seizure prophylaxis is introduced as a common neurosurgical practice. Investigations are still ongoing to figure out the most efficient seizure prophylaxis guideline. Objectives: To compare the efficacy of two seizures prophylaxis protocols that have been practiced in a tertiary neurovascular center in Southern Iran through a retrospective cohort analysis Methods: A total of 426 patients who were operated due to aneurysmal SAH between September 2007 and March 2016 were included in this retrospective cohort study. From September 2007 to March 2011 the common practice was prophylaxis with phenytoin for 3 -6 months, which was switched to a shorter 1-month course since March 2011. Seizure control was evaluated in telephoned patients and outpatient records. Results: Out of 426 subjects eligible for this study, 165 (38.7%) took the 1-month (short-term) regimen and 261 (61.3%) took the 3 -6 months (long-term) regimen. Results revealed that achievement of seizure control was similar for both groups in those without perioperative seizures (P = 0.4); however, with perioperative seizures, the short-term protocol had inferior results for seizure control and higher odds (almost 109-fold) for developing post-operative seizures. Conclusions: Although short-term 1-month seizure prophylaxis with phenytoin provides adequate seizure control for most individuals after SAH, perioperative seizures necessitates a longer course of 3 -6 month seizure prophylaxis.

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A Randomized Trial of Brief Versus Extended Seizure Prophylaxis After Aneurysmal Subarachnoid Hemorrhage

Cited by 32 publications

References 15 publications

Augmented Renal Clearance

Augmented Renal Clearance

Principles of Pharmacotherapy of Seizures and Status Epilepticus

Long-Versus Short-Term Seizure Prophylaxis After Craniotomy for Clipping in Aneurysmal Subarachnoid Hemorrhage; A Retrospective Cohort Study

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