Aneurysmal subarachnoid hemorrhage (aSAH) and spontaneous intracranial hemorrhage (ICH) are
frequently associated with epileptic complications. The use of anti-epileptic drugs (AEDs) for seizure prophylaxis,
however, is controversial. In patients with aSAH, nonconvulsive status epilepticus has been associated with
poor outcome. Effect of other forms of less severe epileptiform activity on clinical outcome remains unclear.
Evidence on efficacy of AEDs in reducing seizure incidence is also mixed. However, increasing number of studies
suggest that AEDs may have significant adverse effects on outcome, especially with phenytoin. Similarly, in
patients with ICH, the impact of seizures that do not progress to status epilepticus on clinical outcome is controversial,
and whether prophylactic AED use has independent effects on outcome remains ambiguous. Currently,
there are no large scale randomized control trials investigating the efficacy and safety of AED prophylaxis in
patients with hemorrhagic stroke. There are also no trials comparing the efficacy and safety of the different
AEDs. Survey based studies have found a wide range of prescribing patterns across treatment centers and clinicians
for seizure prophylaxis in patients with hemorrhagic stroke. The lack of clear guidelines and recommendations
also highlights the paucity of good quality evidence in this area. In conclusion, a well-designed randomized,
double blinded, and appropriately powered trial is needed to evaluate the incidence as well as clinical outcomes in
patients with aSAH and ICH who received AED prophylaxis versus controls. The results will be extremely valuable
in providing evidence to establish management guidelines for patients with hemorrhagic stroke.