Objective : This study was designed to to analyze the associated risk factors of seizure after aneurysmal subarachnoid hemorrhage(SAH) for providing guidelines of prophylactic antiepileptic drug administration. 
Method : We retrospectively reviewed the programmed clinical database and radiographic findings of the patients with aneurysmal SAH who were treated from March 1996 to August 2004 and followed up for more than one year. 
Result : A total of 512 patients were enrolled. 20 patients (3.9%) presented with seizures. Aneurysm location and size were not associated with seizures. The incidence of seizure was significantly different in the Hunt & Hess Grade IV patients (8.6%) and V patients (23.1%). Fisher Grade IV was associated with a significantly higher risk of the seizure (12.2%). The incidence of seizure was higher in patients with hydrocephalus (6.7%), intracerebral hematoma (8.8%), and decompressive lobectomy (14.3%). 
Conclusion : The overall incidence of seizures was 3.9%. Risk factors of seizures were poor clinical grade (Hunt &Hess Grade IV and V), higher Fisher Grade (IV), hydrocephalus, intracerebral hematoma, and decompressive lobectomy.ope

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IntroductionPost-operative seizures are well-known complications ofruptured cerebral aneurysm, but incidence and risk factorshave differed among reports.11) 15) 16) 22) 25) 27-31) 33) 36) The reportedrisk of seizure after surgery for ruptured cerebral aneurysmshas varied between 3% and 27.5%.1-6)8-16)19-26)29-36) Suchinconsistency may be due to different criteria for patientselection, variable follow-up periods, and different timingand methods of surgery.Post-operative seizure after ruptured cerebral aneurysm iswell-established. The effect of craniotomy, however, has notbeen well evaluated.1)5)8)15)16)18)19)26)30) Additionally, there are fewreports of seizures after coil embolization for rupturedcerebral aneurysm.4)The use of anti-epileptic drug (AED) after aneurysmal surgeryis common, but treatment duration, efficacy, and scientificsupport for AED usage are not well-established.2)7)30)31)35)This study was designed to find the risk factors of seizuresafter aneurysmal surgery, and to provide guideline forprophylactic AED administration.Materials and MethodsAneurysmal SAH patients, treated from March 1996 toAugust 2004, were reviewed retrospectively. Patients whowere not followed for at least one year or who had aprevious history of seizure or epilepsy were excluded.Variables included age, sex, Hunt-Hess grade, Fisher grade,aneurysm location, delayed ischemic neurological deficit(DIND), hydrocephalus, intracerebral hemorrhage (ICH),cerebral infarct, and decompressive lobectomy. The Chi-Square test was used for univariate analyses, and Fisher’sExact Test was used when the population is too small so thatRisk Factors of Seizures Associated with the Management of Ruptured Cerebral AneurysmsDepartment of Neurosurgery, Yonsei University College of Medicine, Seoul, KoreaTae-Yup Kim, MD∙Seung-Kon Huh, MD∙Jae-Whan Lee, MD∙Kyu Chang Lee, MDObjective : This study was designed to to analyze the associated risk factors of seizure after aneurysmal subarachnoid hemorrhage(SAH) for providing guidelines of prophylactic antiepileptic drug administration. Method : We retrospectively reviewed the programmedclinical database and radiographic findings of the patients with aneurysmal SAH who were treated from March 1996 to August 2004 andfollowed up for more than one year. Result : A total of 512 patients were enrolled. 20 patients (3.9%) presented with seizures. Aneurysmlocation and size were not associated with seizures. The incidence of seizure was significantly different in the Hunt & Hess Grade IVpatients (8.6%) and V patients (23.1%). Fisher Grade IV was associated with a significantly higher risk of the seizure (12.2%). Theincidence of seizure was higher in patients with hydrocephalus (6.7%), intracerebral hematoma (8.8%), and decompressive lobectomy(14.3%). Conclusion : The overall incidence of seizures was 3.9%. Risk factors of seizures were poor clinical grade (Hunt &Hess Grade IVand V), higher Fisher Grade (IV), hydrocephalus, intracerebral hematoma, and decompressive lobectomy. (Kor J CerebrovascularSurgery 8:10-4, 2006)KEY WORDS : Seizure∙Subarachnoid hemorrhage∙Cerebral aneurysm논문접수일 : 2006년 6월 14일심사완료일 : 2006년 7월 4일교신저자 : Seung-Kon Huh, MD, Department of Neurosurgery,Yonsei University College of Medicine, Shinchon-dong 134,Seodaemun-gu, Seoul 120-752, Korea전화 : (02) 2228-2150�전송 : (02) 393-9979E-mail : sk522@yumc.yonsei.ac.krChi-Square Test is not appropriate. The parameters provedto be statistically significant in univariate analyses were re-analyzed by multivariate logistic regression analysis.Statistical significance was defined as a p-value less than0.05.ResultsA total of 512 patients were enrolled. 189 patients weremale, and the male to female ratio was 1:1.8. The mean agewas 48.2 years, and the mean follow-up period was 50.1months. The mean duration of AED usage was 12 months.451 patients were treated with aneurysmal neck clipping and61 patients with coil embolization of the aneurysm. Amongthe 512 patients, 20 patients (3.9%) presented with seizures.The incidence of seizure was 4.2% in the group of ageyounger than 40 year old, 4.8% in the age of fifties, 3.6% inthe sixties, and 4.1% in the seventies. There was nosignificant difference of seizure incidence between differentage groups (Table 1). Table 2 shows the locations of theruptured cerebral aneurysms. The incidence of seizure was3.5% in the group of internal carotid artery (ICA) aneurysm,5.0% in the group of middle cerebral artery (MCA)aneurysm, 4.2% in the group of anterior communicatingartery (AComA) aneurysm, and 2.8% in the vertebrobasilarartery aneurysm. In case of the ruptured aneurysms in theMCA and AComA, the incidence of seizure was slightlyhigher than others but statistically not significant. Theincidence of seizure was 3.7% in the group of smallaneurysm (smaller than 5 mm in diameter), 3.8% in thegroup of the aneurysm size from 6 mm to 10 mm, and 5.6%in those with large aneurysm (larger than 10 mm). Aneurysmsize was not related to seizure occurrence (Table 3). None ofpatients in the Hunt-Hess Grade I showed seizure. 1.2% ofthe patients In Grade II, 3.8% in Grade III, 8.6% in GradeIV, and 23.1% in Grade V had seizures. Higher Hunt & HessGrade had higher incidence of seizures significantly (Table4). The Amount of SAH affected the incidence of seizures;2.5% in Fisher Group I, 1.3% in Group II, 3.3% in Group III.Fisher Group was significantly associated with the risk ofseizure (9 of 74 patients in Group IV, 12.2%) (Table 5).Table 6 reveals the relationship between the various clinicalparameters and seizures. Six of 85 patients (7.1%) withDIND had seizures, however, it was not statisticallysignificant. Among 194 patients with hydrocephalus, 13patients (6.7%) developed seizures. Hydrocephalus wasKor J Cerebrovascular Surgery 8:10-4, 2006related to a significantly higher risk of seizure. In patientswith ICH, the incidence of seizure was also significantlyhigher (8.7%). Patients with cerebral infarct present highincidence of seizure (3 of 23, 13.0%). Although thedifference was proved to be not statistical significant due tosmall population (p-value;0.0206 in Chi-Square Test versus0.0547 in Fisher’s Exact Test), it was thought to beassociated with seizures. Among 451 patients treatedsurgically, 34 patients received decompressive cerebrallobectomy. In these patients, 5 (14.7%) presented withseizures, and lobectomy was associated with a significantlyhigher seizure risk. Interestingly, none of the 61 patientstreated with endovascular coil embolization had anyseizures. But, the endovascular procedures was notassociated with seizure risk regardless of age-sex matchedcorrection. With significant factors in univariate analyses(Hunt-Hess grade, Fisher grade, Hydrocephalus, ICH,decompressive lobectomy), multivariate logistic regressionanalysis was performed, and Hunt-Hess grade was onlystatistically significant risk factor (Table 7).DiscussionSeizures after aneurysmal SAH are a well-knowncomplication, but the incidence and risk factors of seizuresvary among previous reports.11)15)16)22)25)27-31)33)36) Theseinconsistencies may be associated with differences in thedefinition of seizure or epilepsy, follow-up period, or patientpopulation. Nonetheless, the incidence of seizures hasdeclined from 10~27%5)29)32) before 1976, to 3~10% morerecently.2)11)15)22)28)30)33)34)35) This change may be due to moreadvanced microsurgical techniques, AEDs, anestheticmethods, and the evolution of management programs.Seizure risk factors also vary among reports. Thefollowing have all been reported as risk factors: younger age,middle cerebral artery aneurysms, intracerebral hematoma,poor initial clinical grade, postoperative focal neurologicaldeficit due to cortical infarction, rebleeding, intra-operativedamage including medial temporal lobe retraction, resectionof the gyrus, history of seizures, persistent post-operativedeficit, shunt-dependent hydrocephalus, EEG abnormality,multiple lesions, duration of coma, hypertension, amount ofsubarachnoid hemorrhage, wrapping technique, and onsetseizure.1-6)8-16)19-26)29-36) A number of factors are mentioned inmany reports, but some are reported in only one.In this study, seizures were associated with Hunt-Hessgrade, Fisher grade, hydrocephalus, intracerebral hematoma,and decompressive lobectomy. Patients with cerebral infarctwere so few that it did not show statistical significance, but itis thought to be correlated with seizures. These showed thatKor J Cerebrovascular Surgery 8:10-4, 2006seizures after aneurysmal SAH seemed to be closely relatedto secondary cortical damage. Patients with middle cerebralartery aneurysms had a relatively higher incidence ofseizure, although the difference was not statisticallysignificant. Age was not associated with seizure.Although, Byrne et al, reported that endovascularprocedure seemed to have relatively low risk of seizure dueto low risk of cortical injury,4) there are many obstacles andbiases that complicate the comparison of patients treatedwith endovascular coil embolization or surgery. In thisstudy, despite of no seizure with patients treated byendovascular procedures, endovascular procedures is provednot to be associated with seizure risk. Age-sex matchedcorrection did not affect the result. A larger, randomized,well-planned study is needed to conclude whetherendovascular procedures are associated with low seizurerisk, compared that associated with surgery.There are many controversies surrounding theprophylactic use of AEDs in cases of aneurysmal SAH, andregimens vary in different centers.2)7)30)31)35) Many authorsargue that long-term prophylaxis should be restricted. Byrneet al. discourage prophylactic AED prescription and arguethat it is unnecessary, especially in patients treated solelywith coil embolization.1)2)4)12) Such restrictions seem welladvised, given the lower incidence of seizures in recentreports. Our study also supports reducing AED prophylaxis,although not decisively.ConclusionsThe significant risk factors associated with seizuresfollowing aneurysmal SAH were poor initial Hunt-Hessgrade (IV and V), poor Fisher grade (IV), hydrocephalus,intracerebral hematoma, and decompressive lobectomy.Among these, Hunt-Hess grade was the only high risk factorproven by multivariate regression logistic analyses. Long-term prescription of prophylactic AED was restricted to thehigh-risk patients, as characterized in this study.01) Baker CJ, Prestigiacomo CJ, Solomon RA. Short-termperioperative anticonvulsant prophylaxis for the surgicaltreatment of low-risk patients with intracranial aneurysms.Neurosurgery 37:863-71, 199502) Bidzinski J, Marchel A, Sherif A. Risk of epilepsy afteraneurysm operations. Acta Neurochir (Wien) 119:49-52, 199203) Butzkueven H, Evans AH, Pitman A, Leopold C, Jolley DJ,Kaye AH, et al. Onset seizures independently predict pooroutcome after subarachnoid hemorrhage. 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Occurrence and implicationsof seizures in subarachnoid hemorrhage due to rupturedintracranial aneurysms. Neurosurgery 8:417-21, 198111) Hasan D, Schonck RSM, Avezaat CJJ, Tanghe HLJ, van GijnH, van der Lugt PJM. Epileptic seizures after subarachnoidhemorrhage. Ann Neurol 33:286-91, 199312) Hayashi T, Hadeishi H, Kawamura S, Nonoyama Y, Suzuki A,Yasui N. Postoperative anticonvulsant prophylaxis for patientstreated for cerebral aneurysms. Neurol Med Chir (Tokyo)39:828-33, 199913) Ise H, Yamaura A, Isobe K. Follow-up study of intracranialaneurysms with special reference to long-term socialrehabilitation. Neurol Med Chir (Tokyo) 25:541-50, 198514) Jeffreys RV. Early complications and results of surgery forruptured intracranial aneurysms. Acta Neurochir (Wien)56:39-52, 198115) Keranen T, Tapaninaho A, Hernesniemi J. Late epilepsy afteraneurysm operations. Neurosurgery 17:897-900, 198516) Krayenbuhl HA, Yasargil MG, Flamm ES. Microsurgicaltreatment of intracranial saccular aneurysms. 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Risk Factors of Seizures Associated with the Management of Ruptured Cerebral Aneurysms

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Risk Factors of Seizures Associated with the Management of Ruptured Cerebral Aneurysms

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