A Systematic Appraisal of Neurosurgical Seizure Prophylaxis: Guidance for Critical Care Management

Clinical decisions are often made in the presence of some uncertainty. Health care should be based on a combination of scientific evidence, clinical experience, economics, patient value judgments, and preferences. Seizures are not uncommon following brain injury, surgical trauma, hemorrhage, altered brain metabolism, hypoxia, or ischemic events. The impact of seizures in the immediate aftermath of injury may be a prolonged intensive care stay or compounding of the primary injury. The aim of brain injury management is to limit the consequences of the secondary damage. The original intention of seizure prophylaxis was to limit the incidence of early-onset seizures. However, clinical trials have been equivocal on this point, and there is concern about the adverse effects of antiepileptic drug therapy. This review of the literature raises concerns regarding the arbitrary division of seizures into early onset (7 d) and late onset (8 d and beyond). In many cases it would appear that seizures present within 24 hours of the injury or after 7 days, which would be outside of the scope of current seizure prophylaxis guidance. There also does not appear to be a pathophysiological reason to divide brain injury-related seizures into these timeframes. Therefore, a solution to the conundrum is to reevaluate current practice. Prophylaxis could be offered to those receiving intensive care for the primary brain injury, where the impact of seizure would be detrimental to the management of the brain injury, or other clinical judgments where prophylaxis is prudent. Neurosurgical seizure management can then focus attention on which agent has the best adverse effect profile and the duration of therapy. The evidence seems to support levetiracetam as the most appropriate agent. Although previous reviews have identified an increase cost associated with the use of levetiracetam, current cost comparisons with phenytoin demonstrate a marginal price differential. The aim of this review is to assimilate the applicable literature regarding seizure prophylaxis. The final guidance is a forum upon which further clinical research could evaluate a new seizure prophylaxis paradigm.