Factors Associated with Early and Late Seizure Related to Aneurysmal Subarachnoid Hemorrhage

Abstract

Post-stroke epilepsy may occur after aneurysmal subarachnoid hemorrhage (aSAH). Both early and late seizures could cause severe neurocognitive deficits if administration of appropriate antiseizure medication is delayed. Therefore, it is important to elucidate the risk factors for early and late seizures, which could be shared with medical teams to promptly manage seizures. There are aspects of both hemorrhage and ischemia in aSAH, and thus, numerous risk factors are considered for early and late seizures. We examined factors associated with aSAH-related early and late seizures. Among 297 patients who had aSAH and underwent direct or endovascular surgery, 25 had early seizures and 20 had late seizures. Patients who did not experience any seizures in at least 2-years of follow-up (n = 81) were used as the control group. Early seizures were associated with older age and acute severe nonneurological infection, whereas late seizures were associated with intraparenchymal lesion volume >10 mL and shunt placement. In patients with late seizures, consistency was frequently observed between electroencephalogram and the presence of intraparenchymal lesions. The frontopolar electrode on electroencephalogram was highly sensitive to abnormality in early seizures. Early seizures were induced by the patient's systemic factors, which may lower the threshold for cortical excitability. Patients with intraparenchymal lesions who undergo shunt placement should be carefully followed up for late seizures.

Keywords: aneurysmal subarachnoid hemorrhage; early seizure; electroencephalogram; late seizure.

Fig. 1

Neuroimaging and electroencephalogram of representative cases of early seizure (A) and late seizure (B). Left: Diffuse subarachnoid hemorrhage on CT (upper) and rhythmic delta activity + sharp on bilateral frontopolar, C, T (lower). (Patient 13, 93-year-old woman, Hunt and Hess grade II; Acom ruptured aneurysm treated with coil embolization; NCSE was observed 1 day after admission). Right: Left Sylvian subarachnoid hemorrhage on CT and the previous old infarction and perifocal high intensity in the right temporoparietal area on diffusion weighted imaging. EEG shows spike or polyspike predominantly on P4, consistent with the previously existing lesion (Patient 35, 94-year-old woman, Hunt and Hess grade II, left internal carotid artery posterior communicating artery ruptured aneurysm treated with coil embolization, NCSE was observed 43 days after admission).