Cocaine use as an independent predictor of seizures after aneurysmal subarachnoid hemorrhage

Abstract

OBJECT Seizures are relatively common after aneurysmal subarachnoid hemorrhage (aSAH). Seizure prophylaxis is controversial and is often based on risk stratification; middle cerebral artery (MCA) aneurysms, associated intracerebral hemorrhage (ICH), poor neurological grade, increased clot thickness, and cerebral infarction are considered highest risk for seizures. The purpose of this study was to evaluate the impact of recent cocaine use on seizure incidence following aSAH. METHODS Prospectively collected data from aSAH patients admitted to 2 institutional neuroscience critical care units between 1991 and 2009 were reviewed. The authors analyzed factors that potentially affected the incidence of seizures, including patient demographic characteristics, poor clinical grade (Hunt and Hess Grade IV or V), medical comorbidities, associated ICH, intraventricular hemorrhage (IVH), hydrocephalus, aneurysm location, surgical clipping and cocaine use. They further studied the impact of these factors on “early” and “late” seizures (defined, respectively, as occurring before and after clipping/coiling). RESULTS Of 1134 aSAH patients studied, 182 (16%) had seizures; 81 patients (7.1%) had early and 127 (11.2%) late seizures, with 26 having both. The seizure rate was significantly higher in cocaine users (37 [26%] of 142 patients) than in non-cocaine users (151 [15.2%] of 992 patients, p = 0.001). Eighteen cocaine-positive patients (12.7%) had early seizures compared with 6.6% of cocaine-negative patients (p = 0.003); 27 cocaine users (19%) had late seizures compared with 10.5% non-cocaine users (p = 0.001). Factors that showed a significant association with increased risk for seizure (early or late) on univariate analysis included younger age (< 40 years) (p = 0.009), poor clinical grade (p = 0.029), associated ICH (p = 0.007), and MCA aneurysm location (p < 0.001); surgical clipping was associated with late seizures (p = 0.004). Following multivariate analysis, age < 40 years (OR 2.04, 95% CI 1.355–3.058, p = 0.001), poor clinical grade (OR 1.62, 95% CI 1.124–2.336, p = 0.01), ICH (OR 1.95, 95% CI 1.164–3.273, p = 0.011), MCA aneurysm location (OR 3.3, 95% CI 2.237–4.854, p < 0.001), and cocaine use (OR 2.06, 95% CI 1.330–3.175, p = 0.001) independently predicted seizures. CONCLUSIONS Cocaine use confers a higher seizure risk following aSAH and should be considered during risk stratification for seizure prophylaxis and close neuromonitoring.

Seizures at the onset of aneurysmal SAH: epiphenomenon or valuable predictor?

“…In particular, drug abuse is an acknowledged risk factor for seizures regardless of aSAH [17]. In the setting of aSAH, it has been shown that cocaine use increases the risk of seizures during hospitalization [18]. In our study, individuals with drug abuse were more likely to present with SAO, but this association has failed to remain significant in multivariate analysis.…”

The effects of social contact on cocaine intake under extended-access conditions in male rats.

“…It is significant that the three groups did not differ in the duration of responding, because it suggests that social contact does not influence the loss of circadian control of drug intake that might emerge during an extended binge of cocaine use. Rather, social contact influences the overall amount of cocaine consumed during a binge, which directly impacts the likelihood of an overdose related to stroke, seizure, or myocardial infarction (Chang, Kowalski, Carhuapoma, Tamargo, & Naval, 2016; Klonoff, Andrews, & Obana, 1989; Minor, Scott, Brown, & Winniford, 1991; Ritz & George, 1993). We previously reported that physical activity (i.e., wheel running) reduces cocaine intake during 23-hr test sessions by significantly decreasing the duration of responding and thus preserving the circadian control of behavior (Smith, Walker, Cole, & Lang, 2011).…”

Cocaine and Ischemic or Hemorrhagic Stroke: A Systematic Review and Meta-Analysis of Clinical Evidence

“…One study further failed to find a difference in NIH Stroke Scale at the time of discharge between cocaine users and non-users [ 35 ]. Following stroke, cocaine users were at increased odds of having seizures compared to non-users (OR = 1.61) [ 32 , 36 , 38 ]. In cases of SAH, cocaine use was significantly associated with vasospasm (OR = 2.25) [ 20 , 24 , 29 , 36 , 46 ], with one study reporting a higher rate of aneurysm re-rupture in cocaine users (OR = 3.00) [ 34 ].…”

“… Results from the risk of bias assessment [ 8 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ]. …”