Cerebral infarction following a seizure in a patient with subarachnoid hemorrhage complicated by delayed cerebral ischemia

Abstract

Background:Seizures are a recognized complication of subarachnoid hemorrhage (SAH). They can increase the cerebral metabolic demands and lead to cardiopulmonary compromise. This could be detrimental in the setting of delayed cerebral ischemia (DCI), when the brain tissue is vulnerable to further reductions in oxygen delivery or increases in demand. An association between seizures and worsening ischemia could influence the decision to use antiepileptic drug (AED) prophylaxis in patients with vasospasm.Case Description:A 64-year-old woman developed confusion, aphasia and right hemiparesis on day 7 after aneurysmal SAH. Angiography confirmed severe anterior circulation vasospasm. She initially responded to hypertensive therapy with almost complete resolution of her ischemic neurological deficits. However, on day 10, she had a single generalized seizure and required intubation for airway protection. Her blood pressure dropped with AED initiation, necessitating an increase in the previously stable dose of vasopressors. She developed aphasia and worsening hemiparesis that did not resolve despite hemodynamic augmentation. Subsequent head computed tomographies revealed new infarction in the left anterior cerebral artery territory not present previously. She had received prophylactic phenytoin for only 3 days, as per our SAH protocol.Conclusion:AED prophylaxis is typically used early after SAH when the risk is high and a seizure may precipitate aneurysmal rebleeding. This case illustrates how a later seizure in the setting of vasospasm can lead to decompensation of DCI, with potential for irreversible infarction. Therefore, patients with vasospasm may benefit from extended durations of prophylaxis to prevent such complications.

Risk of Seizures after Endovascular Management of Ruptured Intracranial Aneurysms: A Systematic Review and Meta-analysis

“…In patients who develop seizures, the presence of hypotension and hypoxemia increases the risk of a secondary injury such as ischemic injury and ICP raise. 19 , 20 Interestingly, Patankar and Hughes 21 reported the resolution of temporal lobe epilepsy after coiling of intracranial aneurysms.…”

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

“…In this small single-center study we compared the effectiveness of a short three-day course of LEV (our standard practice and that espoused by recent guidelines [11]) to an extended course continued until discharge. This trial intended to determine whether there was a benefit to longer seizure prophylaxis, based on some institutional data and clinical concerns that risk of seizures persists throughout the hospital stay and may have deleterious consequences [9,12]. We found a trend to more seizures in those receiving only three days of LEV, although this was primarily driven by two excess late seizures in this group.…”