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Background: Antiseizure medication (ASM) use in traumatic brain injuries (TBI) reduces the risk of early post-traumatic seizure (PTS). Agent selection and dosing strategies remain inconsistent among trauma centers in the United States., Objective: The purpose of this study was to identify and characterize the most common PTS prophylaxis regimens among adult trauma centers in brain injured patients throughout the United States., Methods: A survey assessing PTS prophylaxis practices of trauma centers was created and distributed in March 2023. Data was then evaluated based on practice site demographics and various sub-group analyses including academic vs. non-academic centers, trauma center designation, geographic practice location, and total number of TBI activations annually., Results: A total of 84 different trauma centers responded of which, 82 (97.6 %) respondents reporting levetiracetam (LEV) as their ASM of choice for PTS prophylaxis. The most reported dosing regimen included an initial dose of 1000 mg (n = 24, 46.2 %) followed by a maintenance dose of 500 mg BID (n = 39, 48.8 %). There were no statistically significant differences in practice between sub-group analyses evaluated., Conclusion and Relevance: This multicenter, survey study, identified variances in practice for PTS prophylaxis for brain injured patients throughout the U.S. Interestingly, the overwhelming majority of trauma centers do not conform to the Brain Trauma Foundation guidelines and utilize LEV as their agent of choice. Further studies should evaluate ideal patient selection for PTS prophylaxis, optimal agent, and dosing schemes within this cohort., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The incidence of early seizures (occurring within 7 days of stroke onset) after intracerebral haemorrhage reaches 30% when subclinical seizures are diagnosed by continuous EEG. Early seizures might be associated with haematoma expansion and worse neurological outcomes. Current guidelines do not recommend prophylactic antiseizure treatment in this setting. We aimed to assess whether prophylactic levetiracetam would reduce the risk of acute seizures in patients with intracerebral haemorrhage., Methods: The double-blind, randomised, placebo-controlled, phase 3 PEACH trial was conducted at three stroke units in France. Patients (aged 18 years or older) who presented with a non-traumatic intracerebral haemorrhage within 24 h after onset were randomly assigned (1:1) to levetiracetam (intravenous 500 mg every 12 h) or matching placebo. Randomisation was done with a web-based system and stratified by centre and National Institutes of Health Stroke Scale (NIHSS) score at baseline. Treatment was continued for 6 weeks. Continuous EEG was started within 24 h after inclusion and recorded over 48 h. The primary endpoint was the occurrence of at least one clinical seizure within 72 h of inclusion or at least one electrographic seizure recorded on continuous EEG, analysed in the modified intention-to-treat population, which comprised all patients who were randomly assigned to treatment and who had a continuous EEG performed. This trial was registered at ClinicalTrials.gov, NCT02631759, and is now closed. Recruitment was prematurely stopped after 48% of the recruitment target was reached due to a low recruitment rate and cessation of funding., Findings: Between June 1, 2017, and April 14, 2020, 50 patients with mild-to-moderate severity intracerebral haemorrhage were included: 24 were assigned to levetiracetam and 26 to placebo. During the first 72 h, a clinical or electrographic seizure was observed in three (16%) of 19 patients in the levetiracetam group versus ten (43%) of 23 patients in the placebo group (odds ratio 0·16, 95% CI 0·03-0·94, p=0·043). All seizures in the first 72 h were electrographic seizures only. No difference in depression or anxiety reporting was observed between the groups at 1 month or 3 months. Depression was recorded in three (13%) patients who received levetiracetam versus four (15%) patients who received placebo, and anxiety was reported for two (8%) patients versus one (4%) patient. The most common treatment-emergent adverse events in the levetiracetam group versus the placebo group were headache (nine [39%] vs six [24%]), pain (three [13%] vs ten [40%]), and falls (seven [30%] vs four [16%]). The most frequent serious adverse events were neurological deterioration due to the intracerebral haemorrhage (one [4%] vs four [16%]) and severe pneumonia (two [9%] vs two [8%]). No treatment-related death was reported in either group., Interpretation: Levetiracetam might be effective in preventing acute seizures in intracerebral haemorrhage. Larger studies are needed to determine whether seizure prophylaxis improves functional outcome in patients with intracerebral haemorrhage., Funding: French Ministry of Health., Competing Interests: Declarations of interests LP-D reports speaker's honoraria and travel fees from Bioprojet, Jazz Pharmaceuticals, Roche, and UCB. SB reports speaker's honoraria and travel fees from ESAI, Livanona, UCB, and Angelini Pharma. SR reports speaker's honoraria and travel fees from UCB, ESAI, Angelini Pharma, Zogenix, and Gaoma Therapeutics. LD reports speaker's honoraria and travel fees from Alexion, Boehringer Ingelheim, Pfizer, and Servier. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Seizures have been associated with uremia, but there are few data regarding the prevalence, treatment, and outcomes of patients with end-stage renal disease (ESRD) with epilepsy compared to those with ESRD without epilepsy. Here we conducted a retrospective cohort study using the United States Renal Data System to assess mortality and antiseizure medication prescriptions among patients with ESRD with and without a diagnosis of epilepsy. A modified Poisson regression with a robust variance was used to estimate the association between epilepsy status and mortality, and evaluate effect modification by neurology consultation. Additionally antiseizure medications were assessed in relation to mortality among those with epilepsy. Of 148,294 patients with ESRD in the cohort, 13,094 (8.8%) met a claims-based definition for epilepsy. Among those with epilepsy, 80.9% filled an anticonvulsant or hydantoin prescription in 2013-2014, compared to 33.3% without epilepsy. After adjustment for confounders, the mortality risk among those with epilepsy was 1.11 (95% confidence interval: 1.07, 1.14) times higher than those without. An epilepsy diagnosis was associated with a 15% increase in mortality risk among patients who did not have a neurology consultation (relative risk: 1.15 [95% confidence interval: 1.10, 1.20]), but this risk was attenuated among patients with a neurology consultation (1.07 [1.03, 1.11]). Prescription of gabapentin to patients with an epilepsy diagnosis compared to other antiseizure medications was associated with increased mortality (1.08 [1.01, 1.15]). Thus, patients with ESRD treated with dialysis have a high prevalence of epilepsy, which was associated with increased mortality risk compared to those without epilepsy. Hence, appropriate multidisciplinary care, treatment, and medication selection may reduce mortality among dialysis patients with epilepsy., (Published by Elsevier Inc.)

Introduction: We tested the impact of antiepileptic drug (AED) administration on post-cardiac arrest epileptiform electroencephalographic (EEG) activity., Methods: We studied an observational cohort of comatose subjects treated at a single academic medical center after cardiac arrest from September 2010 to January 2018. We aggregated the observed EEG patterns into 5 categories: suppressed; discontinuous background with superimposed epileptiform activity; discontinuous background without epileptiform features; continuous background with epileptiform activity; and continuous background without epileptiform activity. We calculated overall probabilities of transitions between EEG states in a multistate model, then used Aalen's additive regression to test if AEDs or hypothermia are associated with a change in these probabilities., Results: Overall, 828 subjects had EEG-monitoring for 42,840 h with a median of 40 [IQR 23-64] h per subject. Among patients with epileptiform findings on initial monitoring, 50% transitioned at least once to a non-epileptiform, non-suppressed state. By contrast, 19% with non-epileptiform initial activity transitioned to an epileptiform state at least once. Overall, 568 (78%) patients received at least one AED. Among patients with continuous EEG background activity, valproate, levetiracetam and lower body temperature were each associated with an increased probability of transition from epileptiform states to non-epileptiform states, where patients with discontinuous EEG background activity no agent linked to an increased probability of transitioning from epileptiform states., Conclusion: After cardiac arrest, the impact of AEDs may depend on the presence of continuous cortical background activity. These data serve to inform experimental work to better define the opportunities to improve neurologic care post-cardiac arrest., (Copyright © 2019. Published by Elsevier B.V.)

Background: Each year, more than 1.7 million Americans suffer a traumatic brain injury (TBI) and the lifetime prevalence of major depressive disorder following TBI is between 25-50%. There are no validated established strategies to treat TBI depression. Repetitive transcranial magnetic stimulation (rTMS) is a novel putative treatment option for post-TBI depression, which, compared with standard pharmacological agents, may provide a more targeted treatment with fewer side-effects. However, TBI is associated with an increased risk of both early and late spontaneous seizures, a significant consideration in evaluating rTMS as a potential treatment for TBI depression. Whilst the risk of seizure from rTMS is low, underlying neuropathology may somewhat increase that risk., Review: This review focuses on the safety aspects of rTMS in TBI patients. The authors review why low frequency rTMS might be less likely to trigger a seizure than high frequency rTMS and propose low frequency rTMS as a safer option in TBI patients. Because there is little data on the safety of rTMS in TBI, the authors also review the safety of rTMS in patients with other brain pathology., Conclusion: It is concluded that pilot safety and tolerability studies should be first conducted in persons with TBI and neuropsychiatric comorbidities. These results could be used to help design larger randomized controlled trials.

Background: Little is known regarding the timing of childhood vaccination and postvaccination seizures., Methods: In a cohort of 323 247 US children from the Vaccine Safety Datalink born from 2004 to 2008, we analyzed the association between the timing of childhood vaccination and the first occurrence of seizure with a self-controlled case series analysis of the first doses of individual vaccines received in the first 2 years of life., Results: In infants, there was no association between the timing of infant vaccination and postvaccination seizures. In the second year of life, the incident rate ratio (IRR) for seizures after receipt of the first measles-mumps-rubella vaccine (MMR) dose at 12 to 15 months was 2.65 (95% confidence interval [CI] 1.99-3.55); the IRR after an MMR dose at 16 to 23 months was 6.53 (95% CI 3.15-13.53). The IRR for seizures after receipt of the first measles-mumps-rubella-varicella vaccine (MMRV) dose at 12 to 15 months was 4.95 (95% CI 3.68-6.66); the IRR after an MMRV dose at 16 to 23 months was 9.80 (95% CI 4.35 -22.06)., Conclusions: There is no increased risk of postvaccination seizure in infants regardless of timing of vaccination. In year 2, delaying MMR vaccine past 15 months of age results in a higher risk of seizures. The strength of the association is doubled with MMRV vaccine. These findings suggest that on-time vaccination is as safe with regard to seizures as delayed vaccination in the first year of life, and that delayed vaccination in the second year of life is associated with more postvaccination seizures than on-time vaccination., (Copyright © 2014 by the American Academy of Pediatrics.)

Background: Dalfampridine (Ampyra) is indicated to improve walking in patients with multiple sclerosis (MS) and was found to be effective in 35%-43% of individuals with MS in clinical trials. Dalfampridine may increase seizure risk, particularly in patients with renal impairment. A U.S. managed care expert consensus panel agreed that patient access to dalfampridine is best managed by a prior authorization (PA) in accordance with the FDA-approved labeling. To ensure safe and appropriate dalfampridine use, a health plan developed and implemented a 2-phase point-of-sale PA program., Objectives: To evaluate dalfampridine PA review decisions, utilization, and pharmacy expenditures following the implementation of a dalfampridine safety and clinical PA program compared with a group of dalfampridine utilizers unexposed to a PA program., Methods: The study utilized retrospective administrative pharmacy claims data from a commercial health plan averaging 1.3 million members per month. The plan implemented a 2-phase dalfampridine safety and effectiveness PA program on August 1, 2010. A comparison group that did not implement the dalfampridine PA program was identified from a commercially insured population with approximately 350,000 members per month. Members in both groups were required to be continuously enrolled from August 1, 2010, through January 31, 2011. A member's earliest paid or rejected claim found from August 1, 2010, through October 31, 2010, was defined as the index claim. Dalfampridine-weighted 30-day supply claims were summed and compared between groups from index date through January 31, 2011. A pharmacy cost avoidance estimate was calculated using the difference in average claims per member from index claim through January 31, 2011, multiplied by dalfampridine wholesale acquisition cost. Overall, dalfampridine utilization was evaluated between the intervention and comparison populations from August 2010 (implementation of PA in intervention group) through December 2011. Linear regression and Poisson models were used to test the trend differences., Results: The 60 PA-exposed dalfampridine members' average follow-up was 157 days. Phase 1 approval was obtained by 32 (53.3%) members; 4 (6.7%) members received a denial because of renal impairment; 8 (13.3%) members received a denial due to inability to obtain walking time; 1 (1.7%) member with relapse-remitting MS was denied a PA due to no concomitant disease-modifying agent; and 15 (25.0%) members did not initiate the PA process. Phase 2 approval was obtained by 23 (38.3%) of the 60 members. The 60 PA members had a total of 126 claims and an average utilization of 2.1 (SD 1.8) claims per member. The 20 non-PA dalfampridine members' average follow-up was 157 days. The comparison group members had a total of 84 claims and an average utilization of 4.2 (SD 2.0) claims per member. The PA program resulted in an average of 2.1 (P  less than  0.001) fewer claims per member in the PA group. The total dalfampridine cost avoidance estimate was $143,010 or $0.03 per member per month. The overall measure of a monthly claims utilization difference over time was statistically significantly different at P  less than  0.001, using the linear regression slope trend test. The trend line slope was not statistically significantly different, P = 0.841, between the intervention and comparison populations., Conclusions: The study indicates that a dalfampridine PA program potentially improved safety and minimized dalfampridine costs. A PA program is effective in selecting appropriate utilizers for initial therapy. Addition of care management may further optimize use by encouraging adherence and tracking patient response.

On June 10th, 2011, the U.S. Food and Drug Administration approved Potiga (ezogabine) as an add-on medication for the treatment of seizures in adults, and it is being developed by Valeant Pharmaceuticals.

A cerebral aneurysm is an outpouching of a weakened arterial wall, usually at a bifurcation of one of the larger vessels of the Circle of Willis. When the outpouching ruptures, arterial pressure forces blood into the subarachnoid space. The annual incidence of aneurysmal subarachnoid hemorrhage is 8 to 10 per 100 000 in the United States. The outcome varies for this patient population. New management strategies have emerged; some practices are evidence based, whereas others are based on anecdotal experiences. This variation has resulted in a number of unresolved issues in caring for patients with an aneurysmal subarachnoid hemorrhage. This article discusses some of these unresolved issues, including the use of medications such as nimodipine, antifibrinolytics, statins, and magnesium; coiling or clipping for aneurysm securement; and the prevention and treatment of potential complications. Critical care nurses must conduct detailed assessments and provide complex care to optimize patient outcomes.

Objective: Child neurologists and neonatologists often discharge newborn infants with phenobarbital treatment for weeks to months despite the absence of continuing seizure activity. We conducted a national survey to determine the degree of variation in this practice., Methods: Surveys were sent to a randomly generated list of board-certified child neurologists (N = 609) and neonatologists (N = 579). The survey consisted of 3 parts, that is, questions related to overall attitudes and practices, specific patient scenarios, and respondent demographic characteristics. Responses were tabulated and analyzed for all respondents combined and for child neurologists and neonatologists separately. Variation in practices between respondents and the consistency between the respondents' stated use of phenobarbital in practice and their answers to various clinical scenarios were evaluated., Results: Responses were received from 118 child neurologists (20.7%) and 125 neonatologists (23.1%). There was wide variation in practices, with little difference in the response frequencies between child neurologists and neonatologists. Physicians were more likely to respond yes to continuation of phenobarbital treatment in a given clinical situation than would be predicted on the basis of their answers regarding overall frequency of use., Conclusions: Since the survey of practices 15 years ago, child neurologists and neonatologists are reporting less frequent and shorter phenobarbital treatment after resolution of neonatal seizures, although there remains considerable variation in practices. Moreover, what physicians report as their practice in general is inconsistent with how they respond to specific clinical cases of neonatal seizures.

Objective: To investigate the effect of structured didactic lectures by leaders in the field of Maternal-Fetal Medicine on reported clinical decision-making., Methods: An interactive survey of obstetric management was performed as part of a postgraduate course at the 2004 Annual Meeting of the Society for Maternal-Fetal Medicine. Seven controversial topics were addressed, including tocolytic therapy, progesterone supplementation for the prevention of preterm birth, screening for inherited thrombophilia, cervical cerclage for a shortened cervix, the management of preterm premature rupture of membranes, magnesium sulfate seizure prophylaxis, and dexamethasone therapy for hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. The survey was carried out before and after a series of structured didactic lectures, thereby allowing for analysis of the effect of the lectures on reported clinical decision-making., Results: A total of 298 obstetric care providers attended the postgraduate course. By report, the majority of attendees were Maternal-Fetal Medicine specialists (60.7%), less than 10 years out from specialty training (56.3%), and practicing in a university-based setting (52.9%). An average of 233 practitioners (range 157-298) answered each question. Comparison of responses to the survey given before and after the lectures demonstrated significant differences, especially in the areas of tocolytic therapy and inherited thrombophilias., Conclusions: Postgraduate lectures by leaders in the field of Maternal-Fetal Medicine have significant immediate impact on reported clinical decision-making.

Objectives: Pyridoxine is a recommended antidote that should be available in emergency departments (EDs). A pediatric use of this preparation is the treatment of acute seizures secondary to pyridoxine dependency or responsiveness. Two cases of children with pyridoxine-dependent and pyridoxine-responsive seizures whose treatment was affected by the unavailability of pyridoxine in local EDs are presented. These cases prompted the development of a survey to ascertain the availability of parenteral pyridoxine in the pharmacies and EDs of both children's and general hospitals in the United States., Methods: A survey of 203 pharmacy directors in 100 pediatric hospitals (42 self-governing and 58 within a hospital) and 103 general hospitals was conducted. The questionnaire asked for the number of licensed beds and whether injectable pyridoxine was on the formulary and stocked by the ED., Results: The overall response rate was 73% (83% pediatric and 64% general hospitals). Injectable pyridoxine was on the formulary of 99% of pediatric hospitals and 91% of general hospitals (P = 0.044). Of those hospitals that had pyridoxine on the formulary, the availability of injectable pyridoxine in EDs was low in both pediatric (20.7%) and general hospitals (16.7%)., Conclusions: Given the number of possible uses of parenteral pyridoxine in the ED, it is suggested that there is a case for all pediatric and general hospital pharmacies to have it on the formulary and further for all EDs in these hospitals to have injectable pyridoxine available for immediate use.

People with seizures experience restrictions in many areas of life, including participation in recreational activities, social situations, employment, and driving. Health care providers and patients should be informed of the potential hazards faced by people with seizures. The patient and practitioner who know the potential risks can make rational decisions about participation in these activities. Risk assessment and participation should be individualized according to the patient's unique situation. Understanding the inherent risk of a particular activity, risk of recurrence of seizures, legal restrictions (some activities may be governed by law or specific code), seizure type, and adverse effects of medication may be useful in making decisions concerning participation in a wide variety of activities. The information in this article should be used to maximize the patient's quality of life.

Febrile seizures are the most common seizures in childhood and, like all seizures, can be frightening to witness. Therefore, it is not surprising that febrile seizures have been the focus of intense research with an extensive literature describing various preventative measures. In addition, there is also an extensive and sophisticated epidemiological literature delineating the natural history of this disorder in American and British children. For simple febrile seizures, the most common form of this disorder, the epidemiological studies demonstrate a generally benign natural history, making it unlikely that any preventative measure could improve the long term outcome for most children. Children with simple febrile seizures have a slight increased risk of epilepsy, but there are no studies that demonstrate that phenobarbital or other therapy can alter this risk. Daily therapy with phenobarbital or valproic acid can reduce the number of subsequent simple febrile seizures. However, as a recent Practice Parameter from the American Academy of Paediatrics concludes, the risk of adverse effects from daily therapy appears to outweigh the benefit of preventing the short term recurrence of simple febrile seizures. It is possible that in some families, where the occurrence of an additional simple febrile seizure would be particularly distressing, the routine use of oral diazepam during febrile illnesses might be appropriate.