Shubham Misra, Selena Wang, Terence J Quinn, Jesse Dawson, Johan Zelano, Tomotaka Tanaka, James C Grotta, Erum Khan, Nitya Beriwal, Melissa C Funaro, Sravan Perla, Priya Dev, David Larsson, Taimoor Hussain, David S Liebeskind, Clarissa Lin Yasuda, Hamada Hamid Altalib, Hitten P Zaveri, Amr Elshahat, Gazala Hitawala, Ethan Y Wang, Rachel Kitagawa, Abhishek Pathak, Fabien Scalzo, Masafumi Ihara, Katharina S Sunnerhagen, Matthew R Walters, Yize Zhao, Nathalie Jette, Scott E Kasner, Patrick Kwan, Nishant K Mishra
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We aimed to determine outcomes associated with ASMs in people with PSS.</p><p><strong>Methods: </strong>We systematically searched electronic databases for studies on patients with PSS on ASMs. Our outcomes were seizure recurrence, adverse events, drug discontinuation rate, and mortality. We assessed the risk of bias using Cochrane Risk of Bias tool for randomized controlled trials and Risk Of Bias In Non-randomized Studies of Interventions tools. Using levetiracetam as the reference treatment, we conducted a frequentist network meta-analysis and determined the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation methodology.</p><p><strong>Results: </strong>Our search yielded 15 studies (3 randomized, 12 nonrandomized, N = 18,676 patients (121 early and 18,547 late seizures), 60% male, mean age 69 years) comparing 13 ASMs. Three studies had moderate and 12 had high risk of bias. Seizure recurrence was 24.8%. Compared with levetiracetam, very low-certainty evidence suggested that phenytoin was associated with higher seizure recurrences (odds ratio [OR] 7.3, 95% CI 3.7-14.5) and more adverse events (OR 5.2, 95% CI 1.2-22.9). Low-certainty evidence suggested that carbamazepine (OR 1.8, 95% CI 1.5-2.2) and phenytoin (OR 1.9, 95% CI 1.4-2.8) were associated with high drug discontinuation rates. Moderate to high-certainty evidence suggested that valproic acid (OR 4.7, 95% CI 3.6-6.3) and phenytoin (OR 8.3, 95% CI 5.7-11.9) were associated with higher mortality rates. Considering all treatments and using the GRADE approach for treatment ranking, very low-certainty evidence suggested that eslicarbazepine, lacosamide, and levetiracetam had the fewest seizure recurrences. 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Owing to bias and confounding risks, these findings should be interpreted cautiously.</p><p><strong>Trial registration information: </strong>PROSPERO: CRD42022363844.</p>","PeriodicalId":19256,"journal":{"name":"Neurology","volume":"104 3","pages":"e210231"},"PeriodicalIF":7.7000,"publicationDate":"2025-02-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Antiseizure Medications in Poststroke Seizures: A Systematic Review and Network Meta-Analysis.\",\"authors\":\"Shubham Misra, Selena Wang, Terence J Quinn, Jesse Dawson, Johan Zelano, Tomotaka Tanaka, James C Grotta, Erum Khan, Nitya Beriwal, Melissa C Funaro, Sravan Perla, Priya Dev, David Larsson, Taimoor Hussain, David S Liebeskind, Clarissa Lin Yasuda, Hamada Hamid Altalib, Hitten P Zaveri, Amr Elshahat, Gazala Hitawala, Ethan Y Wang, Rachel Kitagawa, Abhishek Pathak, Fabien Scalzo, Masafumi Ihara, Katharina S Sunnerhagen, Matthew R Walters, Yize Zhao, Nathalie Jette, Scott E Kasner, Patrick Kwan, Nishant K Mishra\",\"doi\":\"10.1212/WNL.0000000000210231\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background and objectives: </strong>The most effective antiseizure medications (ASMs) for poststroke seizures (PSSs) remain unclear. 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引用次数: 0
摘要
背景与目的：脑卒中后癫痫发作（pss）最有效的抗癫痫药物（asm）尚不清楚。我们的目的是确定PSS患者与asm相关的结果。方法：系统地检索电子数据库中有关asm中PSS患者的研究。我们的结果是癫痫复发、不良事件、停药率和死亡率。我们使用Cochrane随机对照试验的偏倚风险工具和干预措施的非随机研究的偏倚风险工具评估偏倚风险。使用左乙拉西坦作为参考治疗，我们进行了频率网络荟萃分析，并使用分级推荐评估、发展和评估方法确定了证据的确定性。结果：我们检索了15项研究（3项随机，12项非随机，N = 18,676例患者（早期发作121例，晚期发作18,547例），60%为男性，平均年龄69岁），比较13种asm。3项研究为中度偏倚风险，12项为高偏倚风险。癫痫复发率为24.8%。与左乙西坦相比，极低确定性的证据表明，苯妥英与较高的癫痫发作复发率（比值比[OR] 7.3, 95% CI 3.7-14.5）和更多的不良事件（比值比[OR] 5.2, 95% CI 1.2-22.9）相关。低确定性证据表明卡马西平（OR 1.8, 95% CI 1.5-2.2）和苯妥英（OR 1.9, 95% CI 1.4-2.8）与高停药率相关。中高确定性证据提示丙戊酸（OR 4.7, 95% CI 3.6-6.3）和苯妥英（OR 8.3, 95% CI 5.7-11.9）与较高的死亡率相关。考虑到所有治疗方法并使用GRADE方法进行治疗排序，非常低确定性的证据表明，埃斯卡巴西平、拉科沙胺和左乙拉西坦的癫痫发作复发率最低。低至极低确定性证据表明，拉莫三嗪的不良事件和停药最少，而拉莫三嗪和左乙拉西坦的死亡率较低，证据的确定性为中等。讨论：我们发现左乙拉西坦和拉莫三嗪可能是治疗PSS的安全且可耐受的asm。尽管使用了ASM， PSS人群的癫痫复发率仍然很高。由于存在偏倚和混杂风险，这些发现应谨慎解释。试验注册信息：PROSPERO: CRD42022363844。
Antiseizure Medications in Poststroke Seizures: A Systematic Review and Network Meta-Analysis.
Background and objectives: The most effective antiseizure medications (ASMs) for poststroke seizures (PSSs) remain unclear. We aimed to determine outcomes associated with ASMs in people with PSS.
Methods: We systematically searched electronic databases for studies on patients with PSS on ASMs. Our outcomes were seizure recurrence, adverse events, drug discontinuation rate, and mortality. We assessed the risk of bias using Cochrane Risk of Bias tool for randomized controlled trials and Risk Of Bias In Non-randomized Studies of Interventions tools. Using levetiracetam as the reference treatment, we conducted a frequentist network meta-analysis and determined the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation methodology.
Results: Our search yielded 15 studies (3 randomized, 12 nonrandomized, N = 18,676 patients (121 early and 18,547 late seizures), 60% male, mean age 69 years) comparing 13 ASMs. Three studies had moderate and 12 had high risk of bias. Seizure recurrence was 24.8%. Compared with levetiracetam, very low-certainty evidence suggested that phenytoin was associated with higher seizure recurrences (odds ratio [OR] 7.3, 95% CI 3.7-14.5) and more adverse events (OR 5.2, 95% CI 1.2-22.9). Low-certainty evidence suggested that carbamazepine (OR 1.8, 95% CI 1.5-2.2) and phenytoin (OR 1.9, 95% CI 1.4-2.8) were associated with high drug discontinuation rates. Moderate to high-certainty evidence suggested that valproic acid (OR 4.7, 95% CI 3.6-6.3) and phenytoin (OR 8.3, 95% CI 5.7-11.9) were associated with higher mortality rates. Considering all treatments and using the GRADE approach for treatment ranking, very low-certainty evidence suggested that eslicarbazepine, lacosamide, and levetiracetam had the fewest seizure recurrences. Low to very low-certainty evidence suggested that lamotrigine had the fewest adverse events and drug discontinuations, whereas lamotrigine and levetiracetam exhibited low mortality rates with moderate-certainty evidence.
Discussion: We found that levetiracetam and lamotrigine may be safe and tolerable ASMs for PSS. Despite ASM use, the seizure recurrence rate remains high in the PSS population. Owing to bias and confounding risks, these findings should be interpreted cautiously.
期刊介绍：
Neurology, the official journal of the American Academy of Neurology, aspires to be the premier peer-reviewed journal for clinical neurology research. Its mission is to publish exceptional peer-reviewed original research articles, editorials, and reviews to improve patient care, education, clinical research, and professionalism in neurology.
As the leading clinical neurology journal worldwide, Neurology targets physicians specializing in nervous system diseases and conditions. It aims to advance the field by presenting new basic and clinical research that influences neurological practice. The journal is a leading source of cutting-edge, peer-reviewed information for the neurology community worldwide. Editorial content includes Research, Clinical/Scientific Notes, Views, Historical Neurology, NeuroImages, Humanities, Letters, and position papers from the American Academy of Neurology. The online version is considered the definitive version, encompassing all available content.
Neurology is indexed in prestigious databases such as MEDLINE/PubMed, Embase, Scopus, Biological Abstracts®, PsycINFO®, Current Contents®, Web of Science®, CrossRef, and Google Scholar.
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