| Spontaneous intracerebral hemorrhage is a non-traumatic rupture of blood vessels in the brain that causes blood to accumulate in the brain parenchyma and is second only to ischemic stroke in incidence among all stroke subtypes.Cerebral hemorrhage is a dangerous,lethal,and disabling condition that places a heavy burden on society and families.Compared with western countries,China has a higher rate of intracerebral hemorrhage,accounting for 18.8% to 47.6% of all strokes.Given the large population,the prevention and treatment of intracerebral hemorrhage in China is an even more arduous task.Therefore,efforts to explore effective therapeutic approaches to actively manage cerebral hemorrhage-related complications in order to reduce mortality,reduce disability,and improve patient outcomes are of great significance.In recent years,improvements in medical care have led to significant advances in the diagnosis and treatment of intracerebral hemorrhage.Surgical craniotomy,with its advantages of rapidly clearing hematoma,relieving intracranial hypertension and relieving mechanical pressure,has become an important method in addition to medical treatment of cerebral hemorrhage.However,the current guidelines for the management of intracerebral hemorrhage suggest that the effectiveness of craniotomy for most patients with primary intracerebral hemorrhage is not sufficiently established,and thus do not recommend the indiscriminate routine use of surgery,but rather individual consideration of the patient’s condition.As no uniform standard has been established,the clinician relies on experience to choice it.In these circumstances,it is a practical problem for clinicians to select the indications for craniotomy to maximize the benefit to patients undergoing craniotomy.It is therefore of great importance to understand the present clinical and medical characteristics of patients with spontaneous intracerebral hemorrhage after craniotomy in recent years,to evaluate the cost and benefit of surgery by the clinician,to provide a reference for the choice of indications for craniotomy,and to further optimize the diagnosis and treatment on this basis.Epileptic seizures are episodic,transient brain dysfunctions resulting from abnormal discharges of hypersynchronized neurons in the brain.Severe or prolonged seizures are neurological emergencies that can lead to death.Seizures may be caused by a variety of causes and are a common complication of spontaneous intracerebral hemorrhage,usually classified as acute symptomatic seizures and unprovoked seizures.Unprovoked seizures are more common than acute symptomatic seizures,severely affecting the quality of life of patients with intracerebral hemorrhage.Current guidelines for the management of intracerebral hemorrhage recommend antiepileptic therapy in patients with seizures but do not recommend prophylactic anti-seizure medcations.Consistent with the literature,we observed in clinical practice that unprovoked seizures were more common in ICH patients after craniotomy.However,the concise incidence of unprovoked seizures in patients underwent craniotomy after intracerebral hemorrhage and impact on their outcomes is unclear.Searching for high-risk factors for unprovoked seizures may be more meaningful than treating patients after seizures,because it may help clinicians identify these high-risk patients and further explore the mechanisms underlying epileptogenic,thereby finding ways to prevent unprovoked seizures after intracerebral hemorrhage and to intervene earlier in such patients to improve their outcomes.The first part of this study collected data from patients hospitalized for spontaneous intracerebral hemorrhage in recent years,and analyzed the clinical characteristics.It was found that the group of patients undergoing craniotomy after intracerebral hemorrhage accounts for a considerable proportion of patients in our country,and the prognosis is special,which merits attention.In the second part of the study,we performed Cox regression analyses including craniotomy,as a variables,to find predictors for unprovoked seizures,which is a common complication after intracerebral hemorrhage.We found that patients undergoing craniotomy and presenting with acute symptomatic seizures were identified as a high-risk population for unprovoked seizures after intracerebral hemorrhage.In the third part of the study,we screened patients who underwent craniotomy and classified them according to whether they had received prophylactic anti-seizure medications.We further compared the incidence of unprovoked seizures between the two groups and found no statistical difference.These findings may serve as a guide for optimizing the management of patients with spontaneous intracerebral hemorrhage.Part One Clinical characteristics of patients after spontaneous intracerebral hemorrhagesObjective: To analyze the clinical characteristics of patients after spontaneous intracerebral hemorrhage in order to gain a better understanding of the current status of diagnosis and treatment of these patients.Methods: Patients with acute spontaneous intracerebral hemorrhage were consecutively enrolled from November,2018,through November,2020,at the second hospital of the Hebei Medical University in the East hospital district by searching the electronic medical record system for terms such as "cerebral hemorrhage" and "intracranial hemorrhage" : age at onset,gender,presence of hypertension or diabetes,history of previous intracerebral hemorrhage,imaging features,treatment during hospitalization,presence of acute symptomatic seizures or unprovoked seizures during hospitalization,use of anti-seizure medications,and etiological classification.Outpatient or telephone follow-up was performed after discharge,recording outcomes at 3months,followed by periodic follow-up of unprovoked seizures and survival.Data collected were analyzed retrospectively.Patients who underwent craniotomy and those who did not had craniotomy showed no difference in functional outcome or unprovoked seizures or survival at 3 months after the onset of intracerebral hemorrhage.Results:1.General Data:A total of 635 cases of acute intracerebral hemorrhage were collected during the study period,with a median age of 52(interquartile range,41-60)years.Of these,404(63.6%)were men and 231(36.4%)were women.35 patients(5.5%)died within 7 days after the onset of the disease,496(78.1%)with hypertension,99(15.6%)with diabetes,178(28.0%)with cortical involvement,253(39.8%)with subarachnoid hemorrhage,27(4.3%)with history of cerebral infarction,63(9.9%)with history of cerebral hemorrhage,2(0.3%)with history of epilepsy,6(0.9%)with malignancy,126(19.8%)with use of antiepileptic drugs during hospitalization,89(14.0%)with prophylactic use,37(5.8%)with acute symptomatic seizures,146(23.0%)with open craniotomy(including cranial hematoma evacuation and decompression),489(77%)without open craniotomy(including medical therapy and minimally invasive procedures),and 13(2.0%)with secondary intracranial infection.2.Type of Etiology:Intracerebral hemorrhage was classified according to SMASH-U etiology,with 484 cases of hypertension(76.2%),58 cases of vascular structural injury(9.1%),13 cases of medication(2.0%),8 cases of amyloid degeneration(1.3%),3 cases of systemic disease(0.5%),and 69 cases of unknown cause(10.8%).3.Prognosis:Of 569 patients included in the analysis,100(17.6%)underwent open craniotomy and 469(82.4%)did not.1)Survival:Overall1-month survival was 89.5%(n=509),84.3%(n=480)at 1 year,82.1%(n=467)at 2 years,and 81.0%(n=461)at 3 years without group assignment.In group comparison,patients undergoing open craniotomy had a 1-month survival rate of 64.0%(n=64),a 1-year survival rate of 60.0%(n=60),a 2-year survival rate of 56.0%(n=56),and a 3-year survival rate of 53.0%(n=53).Patients without craniotomy had a 1-month survival rate of 94.8%(n=445),a 1-year survival rate of 89.6%(n=420),a 2-year survival rate of 87.6%(n=411),and a 3-year survival rate of 87.0%(n=408).Survival was significantly different between the 2 groups(P<0.05).2)Functional outcome at 3 months: 125 patients(22.0%)with m RS scores of 4-6 and 444 patients(78.0%)with scores of 0-3 had m RS scores at 3 months without group assignment.In the group comparison,66 patients with m RS scores of 4-6 and 34 with scores of 0-3 had a 3-month follow-up after craniotomy,whereas 59 patients with scores of 4-6 and 410 with scores of 0-3 had a 3-month follow-up without craniotomy,with statistical differences(P<0.05).Part Two Predictors of Unprovoked Seizures in Intracerebral HemorrhagesObjective: To search for predictors of unprovoked seizures after spontaneous intracerebral hemorrhage(ICH)to provide evidence for screening a population at high risk for unprovoked seizures after ICH.Methods: Patients with acute intracerebral hemorrhages admitted to the Department of Neurology,Hebei Medical University Second Hospital between November 2018 and November 2020 were enrolled and data were collected on age at presentation,gender,presence of hypertension or diabetes,history of previous intracerebral hemorrhages,imaging characteristics,volume of hemotoma,presence of acute symptomatic seizures,presence of craniotomy,and use of anti-seizure medications(prophylactic or therapeutic).Patients or their families were followed by telephone to screen for unprovoked seizures and the time when unprovoked seizu res first occurred were recorded.Data were retrospectively analyzed,and univariate and multivariate Cox regression analyses were performed to identify predictors of unprovoked seizures after spontaneous intracerebralh emorrhages.Results:A total of 362 eligible patients completed follow-up.Patients were followed up for 16-36 months(interquartile range:22-28),with amean age of54 years(interquartile range:48-60),230(63.5%)male and 132(36.5%)female.279(77.1%)patients with hypertension,40(11.0%)with diabetes mellitus,36(9.9%)with previous cerebral hemorrhage,64(17.7%)with cortical involvement,115(31.8%)with subarachnoid hemorrhage,45(12.4%)with hyperuricemia,and 53(17.8%)patients underwent craniotomy.Eight(2.2%)patients had acute symptomatic seizures,33(9.1%)had unprovoked seizures,and 3(0.8%)had both episodes.Of the patients who developed unprovoked seizures,30(90.9%)experienced seizures within 12 months after onset,with a median time to onset of 6 months(interquartile range:3-9.25).In univariate analysis,the presence of hypertension(P<0.05,HR: 5.49,95% CI 1.31-22.93),cortical hemorrhage(P<0.05,HR: 3.08,95% CI 1.54-6.15),subarachnoid hemorrhage(P<0.05,HR: 3.53,95% CI 1.73-7.21),craniotomy(P<0.05,HR:12.74,95% CI 6.16-26.31),and acute symptomatic seizures(P<0.05,HR:12.74,95% CI 3.73-12.51)was associated with an increased risk of unprovoked seizures,with statistical significance(P<0.05).In multivariate analysis,the presence of craniotomy(P<0.001,HR: 8.35,95% CI 3.80-18.31)and acute symptomatic seizures(P<0.001,HR: 13.76,95% CI 3.56-53.17)were independent risk factors for unprovoked seizures.Part Three Effect of prophylactic anti-seizure medications on unprovoked seizures in ICH patients with craniotomyObjective: To investigate the effect of prophylactic anti-seizure medications therapy on unprovoked seizures in patients with spontaneous intracerebral hemorrhages after craniotomy.Methods: Data were collected from patients with intracerebral hemorrhages who were admitted to the Department of Neurology,Hebei Medical University Second Hospital,and underwent craniotomy between November 2018 and November 2020 using an electronic medical record system.Data were collected on age at presentation,gender,presence of hypertension,imaging characteristics,volume of hematoma,acute symptomatic seizures,and use of anti-seizure medications(prophylactic or the-rapeutic).Patients or their families were followed by telephone to screenfor unprovoked seizures and the first time when unprovoked seizures o-ccurred were also recorded.The patients were divided into groups acco-rding to whether they received prophylactic anti-seizure medications or not,and statistical analyses were done to compare the two groups in terms of age at onset,gender,hypertension,cortical involvement,subarachnoid hemorrhage,volume of hematoma,acute symptomatic seizures or unprovoked seizures.Results:1.General data: A total of 84 eligible patients completed the follow-up and were included in the analysis.Mean age was 54 years(interquartile range:46.25-62),52(61.9%)were male and 32(38.1%)were female.Mean volume was 61.07±28.6 ml,75(89.3%)patients with hypertension,29(34.5%)with cortical involvement,55(65.5%)with subarachnoid hemorrhage,2(2.4%)with acute symptomatic seizures,and 38 with unprovoked seizures(45.2%).Fifty-three(63.1%)patients did not receive prophylactic anti-seizure medications treatment.Thirty-one(36.9%)patients received prophylactic anti-seizure medications therapy,of whom 23(74.2%)received valproate,six(19.4%)received levetiracetam,and two(6.5%)received valproate plus levetiracetam.2.The relationship between prophylactic anti-seizure medications therapy and unprovoked seizures: We screened 84 patients who underwentcraniotomy and classified them according to with or without prophylacti-c anti-seizure medications to further compare the incidence of unprovok-ed seizures.There were no statistically significant differences in age(P>0.05),gender group(P>0.05),volume of hematoma(P>0.05),hypertensi-on(P>0.05),cortical involvement(P>0.05),or subarachnoid hemorrhage(P>0.05)between groups.Subsequently,we used the Chi-square test to compare incidence of unprovoked seizures between the two groups.There was no statistically significant difference in the incidence of unprovoked seizures between patients with or without prophylactic anti-seizure medications(P>0.05).Conclusions:1.In recent years,hypertension still a major cause of spontaneous intracerebral hemorrhage in our country,with a relatively high proportion of patients having recurrent episodes and a significantly lower mortality rate than20 years ago,but still with a high rate of recurrent episodes and disability,and secondary prevention should be continued.2.Craniotomy and acute symptomatic seizures are two independent risk factors for unprovoked seizures after spontaneous intracerebral hemorrhage.It is recommended that intracerebral hemorrhages patients with these characteristics be followed closely for unprovoked seizures,and further efforts be made to improve outcomes with early intervention in this category.3.Prophylactic anti-seizure medications therapy has not been shown to reduce the incidence of unprovoked seizures of ICH patients underwent craniotomy,and evidence that prophylactic anti-seizure medications is beneficial in this subset of patients is still lacking. |
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