Predictors and incidence of acute seizures after spontaneous intracerebral hemorrhage

Ahmed Esmael; Mohammed El Sherif; Ayman A Elazzouny; Mohamed Abd Elsalam

ORIGINAL ARTICLE

Year : 2016 | Volume : 53 | Issue : 3 | Page : 184-187

Predictors and incidence of acute seizures after spontaneous intracerebral hemorrhage

Ahmed Esmael¹, Mohammed El Sherif¹, Ayman A Elazzouny², Mohamed Abd Elsalam¹
¹ Neurology Department, Mansoura University, Mansoura, Egypt
² Department of Neurology, Misr University for Sciences and Technology, Giza, Egypt

Date of Submission	28-Jul-2015
Date of Acceptance	13-Jan-2016
Date of Web Publication	27-Oct-2016

Correspondence Address:
Mohammed El Sherif
Neurology Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura 35516, Dakahlia
Egypt

Source of Support: None, Conflict of Interest: None

Check

Abstract

Background Different studies have reported the incidence and predictors of seizures in cases of spontaneous intracerebral hemorrhage (sICH) with the possibility of increase in mortality and neurological and medical complications.
Objective This study was designed to identify the incidence and predictors of acute seizures in patients with sICH.
Patients and methods We retrospectively evaluated patients with first-ever sICH hospitalized at the Mansoura Neurology Department (Egypt) over a 1-year period. Important data like age, sex, vascular risk factors, clinical scale scores such as the National Institutes of Health Stroke Scale and the modified Rankin scale scores, intracerebral hemorrhage volume, site, and location, and seizure types were collected.
Results A total of 360 patients with hemorrhagic stroke were studied, comprising 201 men and 159 women, of a mean age of 67.3 ± 12.7 years. The incidence of seizures in sICH was 9%, with statistically significant difference with regard to type (lobar) and location (cortical) of the hematoma (30 and 17 patients, P = 0.002 and 0.003, respectively). In multivariate analysis, the only factors appearing to be independent seizure predictors were cortical hematoma and lobar hematomas.
Conclusion We concluded that relatively old patients with definite lobar and cortical hematomas run a risk for immediate seizures irrespective of hematoma size or clinical state.

Keywords: modified Rankin scale, National Institutes of Health Stroke Scale, seizures, spontaneous intracerebral hemorrhage

How to cite this article:
Esmael A, El Sherif M, Elazzouny AA, Elsalam MA. Predictors and incidence of acute seizures after spontaneous intracerebral hemorrhage. Egypt J Neurol Psychiatry Neurosurg 2016;53:184-7

How to cite this URL:
Esmael A, El Sherif M, Elazzouny AA, Elsalam MA. Predictors and incidence of acute seizures after spontaneous intracerebral hemorrhage. Egypt J Neurol Psychiatry Neurosurg [serial online] 2016 [cited 2023 Mar 20];53:184-7. Available from: http://www.ejnpn.eg.net/text.asp?2016/53/3/184/193088

Introduction

Intracerebral hematoma (ICH) is one of the most important cause of seizures in the elderly [1]. However, the reported incidence of early seizures following ICH has been found to vary significantly in different studies, reportedly ranging from 2.8 to 18.7% [2],[3],[4]. A large number of predictors of seizures were studied, such as size, site, and severity of the vascular lesion, with respect to the occurrence of early seizures but the results were inconsistent and may be contradictory [5]. Indeed, the frequency and predictors of early seizures in ICH are poorly understood [6]. A brief course of anticonvulsant therapy was suggested by Morgenstern and colleagues to reduce the risk for early seizures [7]. Thus, this study was designed to identify the incidence and predictors of acute seizures in cases of spontaneous ICH.

Patients and methods

The present retrospective study included patients with ICH who were admitted to the Neurology Department in Mansoura University Hospital (MUH). The diagnosis was based on clinical assessment and computed tomographic (CT) head scanning immediately after the onset of the condition. On admission the patients were subjected to careful history taking and clinical examination along with administration of the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS). The laboratory investigations included complete blood picture, random blood sugar evaluation, liver and kidney function tests, and assessment of coagulation profile. Electroencephalography was carried out on all patients with seizures. The CT scans were investigated for hematoma volume (the formula ABC/2 was used, where A is the greatest hemorrhage diameter by CT, B is the diameter 90° to A, and C is the approximate number of CT slices with hemorrhage multiplied by the slice thickness) and hematoma location. The study protocol was approved by the Local Ethical Committee at the hospital. All enrolled patients had signed written fully informed consent to participate in the study.

Statistical analysis

Statistical analysis in social science software, version 18.0, was used for statistical analysis (chicago illinois, USA). The χ² statistic was used to compare ICH patients with and without acute seizures. P values less than 0.05 were considered statistically significant. Multivariate analysis was additionally performed using logistic regression models with acute symptomatic seizures (yes/no) as the response variable and seizure predictors found clinically relevant or significant by univariate analysis as covariates. Each covariate was tested independently and with the main interaction terms. Measures of association were odds ratios (OR) with 95% confidence intervals (95% CIs).

Results

A total of 360 patients with hemorrhagic stroke were studied (201 men and 159 women), with a mean age of 67.3 ± 12.7 years. The incidence of ICH was more common in men than in women. The incidence of acute seizures following ICH was higher in men [25 cases with acute seizures (62.5%)] than in women [15 cases with acute seizures (37.5%)]. In our study, the incidence of acute seizures was 9% as it affected 40 patients. The incidence of ICH and acute seizures was more common in elderly patients. The most common risk factor for ICH was hypertension (72%). The incidence of acute seizures increased with increased severity of both NIHSS and mRS score but without statistical significance [Table 1]. The incidence of acute seizures was statistically significantly increased in lobar hematoma than in deep-seated hematoma (P = 0.002). Cortical hematoma was highly associated with the incidence of acute seizures (P = 0.003), but there was no significant correlation between ICH and the incidence of acute seizures [Table 2]. The most common type of seizure was focal epilepsy (65%) [Table 3]. In multivariate analysis the only factors appearing to be independent seizure predictors were cortical hematoma (OR = 6.2; 95% CI = 2–18.9) and lobar hematoma (OR = 3.4; 95% CI = 1.5–8.1) [Table 4].

Table 1: General characteristics of the hemorrhagic stroke patients

Click here to view

Table 2: Radiological features of the hemorrhagic stroke patients

Click here to view

Table 3: Distribution of seizure types among hemorrhagic stroke patients

Click here to view

Table 4: Independent predictors of acute seizures in patients with intracerebral hematoma

Click here to view

Discussion

Our study showed that in a cohort of patients with first-ever hemorrhagic stroke admitted to the Neurology Department in MUH, the incidence of acute symptomatic seizures was 9%. This frequency is higher than that seen in other prospective studies (cumulative incidence ranging from 1.8 to 5.5%) [8],[9],[10],[11]. Seizure risk was highest during the first 24 h and tended to decrease thereafter. This suggests that during acute brain injury accumulation of intracellular calcium and sodium may result in depolarization of the transmembrane potential and other calcium-mediated effects, which may lower the seizure threshold [12]. In our study, the only significant predictors of acute symptomatic seizures were, in decreasing order, lobar hemorrhagic stroke and cortical involvement. Several studies consistently found an association between intracerebral hemorrhage and early seizures [8],[9],[10],[13],[14]. This provides additional evidence in support of the epileptogenic role of blood extravasation. Results from investigating the involvement of the blood digestion system, like hemosiderin, might form the basis of central cerebral aggravation prompting seizures. The cortical location has been consistently found to be associated with poststroke seizures [8],[10],[14],[15],[16]. The true incidences of early, late, and recurrent seizures due to ICH are expected to be higher with a longer follow-up. In contrast, our strict criteria of patient selection might also contribute to the relatively lower incidences of seizures and epilepsy. The present data show that the location of the hematoma is important for the development of seizures. Lobar hematomas had the highest incidence of early seizures. The 75% incidence of seizures in lobar hematomas in this study is similar to that reported by Weisberg et al. [17], who found an incidence of 34% among 50 patients. The incidence of seizure in deep-seated hematomas like thalamic and ganglionic was low (25%). This figure is much higher than the 14% reported by Weisberg et al.[17] and the 22% reported by Lipton et al. [18]. Berger et al.[19] reported that in 19 patients who developed seizures during the acute phase of a supratentorial intracerebral hemorrhage, the seizures were generalized in 13 cases (68%) and focal in six (32%). These data differ from ours. In our study, partial seizures were the most common type, comprising 65% of all seizure types. Complex partial seizures were relatively rare [3 (7.5%)], whereas generalized were 12 (35%). Conflicting observations have been reported previously on the role of hematoma size, however, as both small and large hematomas have been found to increase the risk for seizures, and there have even been reports of no significant effect of hematoma volume on seizure risk [20],[21],[22],[23],[24]. Our result supports the findings of those later studies as immediate seizures were less common among patients with large hematomas when compared for hematoma location (lobar) and site (cortical), with statistical significance.

Conclusion

We concluded that relatively old patients with definite lobar and cortical hematomas run a risk for immediate seizures irrespective of hematoma size and clinical state.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Forsgren L, Bucht G, Eriksson S, Bergmark LIncidence and clinical characterization of unprovoked seizures in adults: a prospective population-based studyEpilepsia199637224229
2.	Hauser WA, Annegers JF, Kurland LTIncidence of epilepsy and unprovoked seizures in Rochester, Minnesota, 1935–1984Epilepsia199334453468
3.	Li X, Breteler MM, de Bruyne MC, Meinardi H, Hauser WA, Hofman AVascular determinants of epilepsy:the Rotterdam StudyEpilepsia19973812161220
4.	Giroud M, Gras P, Fayolle H, André N, Soichot P, Dumas REarly seizures after acute stroke:a study of 1,640 casesEpilepsia199435959964
5.	Beghi E, D'Alessandro R, Beretta S, Consoli D, Crespi V, Delaj L et al.Incidence and predictors of acute symptomatic seizures after strokeNeurology20117717851793
6.	Claassen J, Jetté N, Chum F, Green R, Schmidt M, Choi H et al.Electrographic seizures and periodic discharges after intracerebral hemorrhageNeurology20076913561365
7.	Morgenstern LB, Hemphill JC3rd, Anderson C, Becker K, Broderick JP, Connolly ESJr et al.Guidelines for the Management of Spontaneous Intracerebral Hemorrhage A Guideline for Healthcare Professionals From the American Heart Association/American Stroke AssociationStroke20104121082129
8.	Alberti A, Paciaroni M, Caso V, Venti M, Palmerini F, Agnelli GEarly seizures in patients with acute stroke: frequency, predictive factors, and effect on clinical outcomeVasc Health Risk Manag20084715720
9.	Kilpatrick CJ, Davis SM, Tress BM, Rossiter SC, Hopper JL, Vandendriesen MLEpileptic seizures in acute strokeArch Neurol199047157160
10.	Bladin CF, Alexandrov AV, Bellavance A, Bornstein N, Chambers B, Coté R et al.Seizures after stroke:a prospective multicenter studyArch Neurol20005716171622
11.	Giroud M, Gras P, Fayolle H, André N, Soichot P, Dumas REarly seizures after acute stroke: a study of 1,640 casesEpilepsia199435959964
12.	Lambrakis CC, Lancman METhe phenomenology of seizures and epilepsy after strokeJ Epilepsy199811233240
13.	Szaflarski JP, Rackley AY, Kleindorfer DO, Khoury J, Woo D, Miller R et al.Incidence of seizures in the acute phase of stroke:a population-based studyEpilepsia200849974981
14.	Lamy C, Domigo V, Semah F, Arquizan C, Trystram D, Coste J, Mas JLPatent Foramen Ovale and Atrial Septal Aneurysm Study GroupEarly and late seizures after cryptogenic ischemic stroke in young adultsNeurology200360400404
15.	Misirli H, Ozge A, Somay G, Erdoğan N, Erkal H, Erenoğlu NYSeizure development after strokeInt J Clin Pract20066015361541
16.	Dhanuka AK, Misra UK, Kalita JSeizures after stroke: a prospective clinical studyNeurol India2001493336
17.	Weisberg LA, Shamsnia M, Elliott DSeizures caused by nontraumatic parenchymal brain hemorrhagesNeurology19914111971199
18.	Lipton RB, Berger AR, Lesser ML, Lantos G, Portenoy RKLobar vs thalamic and basal ganglion hemorrhage: clinical and radiographic featuresJ Neurol19872348690
19.	Berger AR, Lipton RB, Lesser ML, Lantos G, Portenoy RKEarly seizures following intracerebral hemorrhage: implications for therapyNeurology19883813631365
20.	Passero S, Rocchi R, Rossi S, Ulivelli M, Vatti GSeizures after spontaneous supratentorial intracerebral hemorrhageEpilepsia20024311751180
21.	Yang TM, Lin WC, Chang WN, Ho JT, Wang HC, Tsai NW et al.Predictors and outcome of seizures after spontaneous intracerebral hemorrhage. Clinical articleJ Neurosurg20091118793
22.	Woo KM, Yang SY, Cho KTSeizures after spontaneous intracerebral hemorrhageJ Korean Neurosurg Soc201252312319
23.	De Herdt V, Dumont F, Hénon H, Derambure P, Vonck K, Leys D, Cordonnier CEarly seizures in intracerebral hemorrhage:incidence, associated factors, and outcomeNeurology20117717941800
24.	De Reuck J, Hemelsoet D, Van Maele GSeizures and epilepsy in patients with a spontaneous intracerebral haematomaClin Neurol Neurosurg2007109501504