Effects of new-generation antiepileptic drug prophylaxis on delayed neurovascular events after aneurysmal subarachnoid hemorrhage

Abstract

Abstract Neuroelectric disruptions such as seizures and cortical spreading depolarization may contribute to the development of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH). However, effects of antiepileptic drug prophylaxis on outcomes remain controversial in SAH. The authors investigated if prophylactic administration of new-generation antiepileptic drugs levetiracetam and perampanel was beneficial against delayed neurovascular events after SAH. This was a retrospective single-center cohort study of 121 consecutive SAH patients including 56 patients of admission World Federation of Neurological Surgeons grades IV−V who underwent aneurysmal obliteration within 72 hours post-SAH from 2013 to 2021. Prophylactic antiepileptic drugs differed depending on the study terms: none (2013−2015), levetiracetam for patients at high risks of seizures (2016−2019), and perampanel for all patients (2020−2021). The 3rd term had the lowest occurrence of delayed cerebral microinfarction on diffusion-weighted magnetic resonance imaging and the tendency of reduced DCI. Other outcome measures were similar among the 3 terms including incidences of angiographic vasospasm, computed tomography-detectable delayed cerebral infarction, seizures, and 3-month good outcomes (modified Rankin Scale 0−2). The present study suggests that prophylactic administration of levetiracetam and perampanel at least does not worsen outcomes, and that perampanel may have the potential to reduce DCI by preventing microcirculatory disturbances after SAH. Further studies are warranted to investigate anti-DCI effects of a selective α-amino-3-hydroxy-5-methyl-4-isoxazole propionate receptor antagonist perampanel in SAH patients in a large-scale prospective study.