Real-World Antiseizure Medication Prophylaxis and Outcomes in Hospitalized Adults with Acute Brain Injuries.

Background: There is low-quality evidence for antiseizure medication (ASM) prophylaxis in acute brain injuries. We examined ASM prophylaxis patterns and explored the association with hospital outcomes in acute brain injury.

Methods:  We analyzed the PINC AI Healthcare Database with data from more than 1,400 US hospitals. We included adults aged ≥ 18 years admitted for at least 2 days with acute brain injury (International Classification of Diseases codes for ischemic stroke [IS], hemorrhagic stroke [HS], and traumatic brain injury [TBI]) and excluded potential prevalent users and patients with epilepsy/seizures. Index date was the second day of admission. The ASM prophylaxis cohort received levetiracetam or phenytoin on the index date; the control cohort did not receive any ASM on the index date. Outcomes were time-to-mortality and time-to-home discharge.

Results: In total, 739,213 patients were eligible: 568,254 with IS, 86,842 with HS, and 84,117 with TBI. ASM prophylaxis was prescribed in 10,959/568,254 (2%) patients with IS, 31,970/86,842 (37%) patients with HS, and 38,331/84,117 (46%) patients with TBI. Patients on prophylaxis more frequently received mechanical ventilation, craniectomies/craniotomies, vasopressors, and anesthetics. After adjusting for markers of illness severity, prophylaxis was associated with mortality (IS: hazard ratio [HR] 2.02, 95% confidence interval [CI] 1.89-2.16; HS: HR 0.83; 95% CI 0.79-0.87; TBI: HR 0.97, 95% CI 0.89-1.06). Prophylaxis was associated with lower home discharge (IS: HR 0.40, 95% CI 0.37-0.42; HS: HR 0.61, 95% CI 0.58-0.64; TBI: HR 0.69, 95% CI 0.68-0.72). Across all acute brain injuries, mechanical ventilation exhibited strong association with outcomes.

Conclusions: Antiseizure medication prophylaxis was higher in TBI and HS compared with IS. Markers of illness severity (e.g., mechanical ventilation, neurosurgical procedures) were associated with more frequent prophylaxis. Prophylaxis exhibited differential associations with mortality (higher in IS, lower in HS and TBI). Prophylaxis was associated with lower home discharge across all acute brain injuries. We hypothesize that neurologic severity and critical illness severity are primary drivers of outcomes. However, the independent association of ASMs with outcomes warrants further investigation.