Introduction: Seizure following subarachnoid hemorrhage occurs in 6-18% of patients with a ruptured intracranial aneurysm. Not only may seizure confound the neurologic exam, but it may also place patients with an unsecured lesion at increased risk for re-rupture. Seizure prophylaxis after subarachnoid hemorrhage is controversial, and there remains no level I data regarding its safety or efficacy.

Methods: A brief 8-question survey was sent to 20 major US centers with cerebrovascular neurosurgical specialization. Respondents were asked about institutional practices regarding seizure prophylaxis, including preferred medications and duration of therapy, as well as seizure surveillance with electroencephalography.

Results: All 20 survey requests were completed and returned. Eleven (55%) respondents endorsed the utility of seizure prophylaxis, while 7 (35%) did not, and 2 (10%) were unsure. Fourteen (70%) reported routine use of an anti-convulsant for seizure prophylaxis, while 6 (30%) did not. Among respondents using prophylaxis, levetiracetam was the first-line medication for the majority (95%), while phenytoin was used as a primary agent at 1 (5%) center and as a secondary agent at 4 (20%) centers. The duration of levetiracetam prophylaxis ranged from 1 day to 6 weeks following SAH, while 6-10 days was most common. Only a single center employed EEG routinely in all aSAH patients, however most supported EEG use when the neurologic exam was unreliable or inexplicably declining. Nineteen (95%) respondents agreed that a trial randomizing patients to levetiracetam or no anti-seizure medication is warranted, and all 20 (100%) believed that such a trial would be ethical.

Conclusions: The routine use of seizure prophylaxis following aneurysmal subarachnoid hemorrhage is controversial. Among a sampling of 20 major academic centers, most administer prophylaxis, while a significant proportion does not. The majority believes a trial randomizing patients to receive seizure prophylaxis is both timely and ethical.

Patient Care: It will allow practitioners to understand the practices of experts in the field regarding seizure prophylaxis in this population, and it will prepare clinicians for a forthcoming trial on the topic.

Learning Objectives: 1) Identify the controversy surrounding seizure prophylaxis following subarachnoid hemorrhage, and 2) Understand the discrepancy among leading cerebrovascular centers regarding the approach to seizures prophylaxis and surveillance.

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