Prophylactic use of antiepileptics in spontaneous intracerebral hemorrhage: a systematic review and meta-analysis focusing on early seizures and clinical determinants.

BACKGROUND AND PURPOSE: Seizures are a common complication after spontaneous intracerebral hemorrhage (SICH), but whether prophylactic anti-seizure medications (ASMs) reduce early seizures (≤ 7 days post-SICH) remains unclear. Moreover, the factors influencing clinicians' decisions regarding prophylactic ASMs are poorly characterized. This systematic review and meta-analysis aimed to determine whether prophylactic ASMs reduce early seizures after SICH, to evaluate their effects on late seizures and functional outcomes, and to identify patient characteristics associated with prophylactic ASMs use. METHODS: The Pubmed, Embase and Cochrane database were searched for studies comparing prophylactic ASMs use versus no prophylaxis in adult patients with SICH. The primary outcomes were early seizures and late seizures. Secondary outcomes included mortality and modified Rankin Scale score (mRS) ≥ 3 at the longest follow-up. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using random-effects models. RESULT: A total of 22 studies comprising 8288 patients were included. Prophylactic ASMs use significantly reduced the risk of early seizures (OR, 0.39; 95% CI 0.20-0.76, p = 0.006, I2 =0%). However, no significant association was found for late seizures (OR, 1.09; 95% CI 0.74-1.59; p = 0.670, I2 = 21.2%) and mortality (OR, 0.90; 95% CI 0.68-1.19, P = 0.467, I2 = 46.1%). Regarding prescribing patterns, patients with lobar hemorrhage (OR, 2.78; 95% CI, 2.06-3.73; p < 0.001) or those undergoing surgical intervention (OR, 3.69; 95% CI, 2.51-5.44; p < 0.001) were significantly more likely to receive prophylactic ASMs. CONCLUSION: Prophylactic ASMs are effective in preventing early seizures after SICH but do not reduce late seizures or improve long-term functional outcomes. Clinicians selectively target prophylaxis to patients with lobar hemorrhage or those undergoing surgery, reflecting guideline-permitted flexibility for high-risk subgroups.