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Guidelines for Seizure Prophylaxis in Patients with Aneurysmal Subarachnoid Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society

Neurocritical Care Society · 2026 · USA

Source and licence

Authors
A. Shaun Rowe, Sahar F. Zafar, Eljim Tesoro et al.
Title
Guidelines for Seizure Prophylaxis in Patients with Aneurysmal Subarachnoid Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society
Journal
Neurocritical Care, 2026
DOI
10.1007/s12028-026-02614-z
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC13642444

Licence statement of the original publication

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Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Introduction

  • Should antiseizure medication versus no antiseizure medication be used in adult patients hospitalized for aneurysmal subarachnoid hemorrhage who have no history of clinical or electrographic seizures?Level of recommendation,quality (certainty) of evidence: Should antiseizure medication versus no antiseizure medication be used in adult patients hospitalized for aneurysmal subarachnoid hemorrhage who have no history of clinical or electrographic seizures?
  • Given the uncertainty in benefits and harms, we suggest either that prophylactic ASM be used or withheld or no ASM be used in patients with aneurysmal subarachnoid hemorrhageLevel of recommendation,quality (certainty) of evidence: Conditional recommendation, low quality of evidence
  • If antiseizure medication is used, should levetiracetam or phenytoin/fosphenytoin be preferentially used for adult patients with aneurysmal subarachnoid hemorrhage and no history of clinical or electrographic seizures?Level of recommendation,quality (certainty) of evidence: If antiseizure medication is used, should levetiracetam or phenytoin/fosphenytoin be preferentially used for adult patients with aneurysmal subarachnoid hemorrhage and no history of clinical or electrographic seizures?
  • We suggest either prophylactic levetiracetam or phenytoin/fosphenytoin in adult patients with aneurysmal subarachnoid hemorrhageLevel of recommendation,quality (certainty) of evidence: Conditional recommendation, very low quality of evidence
  • If an antiseizure medication is used, should a long (> 7 days) or short (≤ 7 days) duration of prophylaxis be used in adult patients with aneurysmal subarachnoid hemorrhage and no history of clinical or electrographic seizures?Level of recommendation,quality (certainty) of evidence: If an antiseizure medication is used, should a long (> 7 days) or short (≤ 7 days) duration of prophylaxis be used in adult patients with aneurysmal subarachnoid hemorrhage and no history of clinical or electrographic seizures?
  • Regarding the duration of antiseizure medications, because of the uncertainty of benefits and harm, we suggest that the decision to use either short- or long-term therapy with ASM as prophylaxis in adult patients with aneurysmal subarachnoid hemorrhage be individualized to each patientLevel of recommendation,quality (certainty) of evidence: Conditional recommendation, moderate quality of evidence

Abstract

Background: There are limited data to guide antiseizure medication (ASM) prophylaxis in patients with aneurysmal subarachnoid hemorrhage (SAH). This results in practice variation in the use and duration of ASM prophylaxis.

Methods: We conducted a systematic review and meta-analysis of articles assessing ASM prophylaxis in adults with aneurysmal SAH. The population, intervention, comparator, and outcome (PICO) questions were as follows: (1) Should ASM or no ASM be used in patients hospitalized for aneurysmal subarachnoid hemorrhage who have no history of clinical or electrographic seizures? (2) If an ASM is used, should levetiracetam or phenytoin/fosphenytoin be preferentially used? (3) If an ASM is used, should a long (> 3 days) or short (≤ 3 days) duration of prophylaxis be used? The main outcomes were early seizure (≤ 14 days), late seizures (> 14 days), adverse events, mortality, and functional outcomes. We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to generate recommendations.

Results: The initial literature search yielded 1988 articles, of which 10 formed the basis of the recommendations: Regarding PICO 1, we did not find a significant difference in outcomes of early seizure, adverse events, mortality, or functional outcomes when comparing ASM to no ASM. In regard to PICO 2, we found fewer early seizures with phenytoin/fosphenytoin and lower risk for neurologic decline with levetiracetam; however, there was low certainty of evidence. There was no significant difference in mortality between the different treatment types. Regarding PICO 3, we found extended use of ASM may be associated with lower seizure risk, but at the same time be associated with higher risk for adverse effects.

Conclusions: Overall, the quality of evidence is low, precluding strong recommendations. We suggest that ASM or no ASM may be used in patients hospitalized with aneurysmal subarachnoid hemorrhage (conditional recommendation, low quality of evidence). If used, we suggest either levetiracetam or phenytoin/fosphenytoin (conditional recommendation, very low quality of evidence) for a short or long duration (conditional recommendation, moderate quality of evidence).

Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1007/s12028-026-02614-z.

Contents of the original publication

The section headings of the original.

  • Introduction
  • Methods
  • Panel Composition
  • PICO Generation
  • Study Population
  • Inclusion and Exclusion Criteria
  • Search Strategy
  • Study Screening and Data Collection
  • Risk of Bias and Certainty of Evidence Evaluation
  • Statistical Analyses
  • Development of Recommendations
  • Results
  • Discussion
  • PICO 1
  • PICO 2
  • PICO 3
  • Conclusions

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