or fosphenytoin (20 mg/kg) (Class I, Level of Evidence B; Figure 3).

An alternative to
phenytoin infusion is levetiracetam (500 mg q12h, adjusted for renal insufficiency). Side
effects of phenytin infusions include rash, hypotension, arrhythmias, and severe
hypocalcemia for the phosphenytoin presentation. Patients with ICH may benefit from
prophylactic anti-epileptic drug therapy, but no randomized trial has addressed the efficacy of
this approach. The American Heart Association Guidelines have recommended anti-epileptic
medication for up to one month, after which therapy should be discontinued in the absence of
seizures. This recommendation is supported by the results of a recent study that showed that
the risk of early seizures was reduced by prophylactic antiepileptic drug therapy [95]. The 30day risk for convulsive seizures after ICH is approximately 8%, and the risk of overt status
epilepticus is 1% to 2%. Lobar location and small hematomas are independent predictors of
early seizures.
The argument for prophylactic anticonvulsant therapy in stuporous or comatose ICH patients
is bolstered by the fact that continuous electroencephalogram monitoring demonstrates
electrographic seizure activity in approximately 25% of these patients, despite prophylactic
anti-epileptic drug therapy. The risk of late seizures or epilepsy among
survivors of ICH is 5% to 27%.