To identify determinants of Prophylactic Antiseizure Medication (pASM) use in the Neurocritical Care Unit (NICU) following strokes. 

Although use of pASM after subarachnoid hemorrhage (aSAH), intracerebral hemorrhage (ICH), or acute ischemic stroke (AIS) is not recommended, it is often initiated in stroke patients. Factors influencing this practice remain unclear.

Of 235 patients screened, 174 were included in the analysis; 67 (38.5%) of which were started on pASM. Stroke subtypes included AIS (47.7%), ICH (33.9%), and aSAH (18.4%).

Patients started on pASM were younger (median age = 59 years, IQR 52-68 vs 65 years, IQR 56-75; p=0.002) and had lower median GCS (12 vs 14, p=0.01). Use of pASM was more common in hemorrhagic strokes (67% vs 7.2%, p<0.001); and among hemorrhagic, mostly in aSAH (87.5% vs 55.9%, p=0.002).  

pASM use was highest in global pathology (86.4%) vs lobar (35.4%, p<0.0001), infratentorial (31.3%, p<0.0001), and deep (28.6%, p<0.0001). Notably, most patients with SI were started on pASMs: hemicraniectomy (82.4%), EVD insertion (72%), hematoma evacuation (95.5%), and aneurysm clipping (100%).  

ICU and hospital length of stay (LOS) were significantly longer in the pASM group (p< 0.0001) and 5.2% of patients were discharged on pASM.  

Multivariable regression demonstrated SI as the strongest predictor of pASM use (OR 10.56, 95% CI 3.66–30.47, p<0.001). Non-hemorrhagic (OR 0.07, 95% CI 0.03–0.19, p<0.001) and non-global location of strokes (OR 0.56, 95% CI 0.32–0.97, p=0.04) were less likely to receive pASM.

Use of pASM was highest in aSAH and global pathology, strongly linked to SI, and associated with prolonged LOS. These findings demonstrate the need for better alignment with evidence-based guidelines.