Epileptic seizures are a common complication at the acute phase of intracerebral haemorrhage (ICH). The incidence of seizures occurring within 7 days reaches 40% when subclinical seizures are diagnosed by continuous electroencephalogram (EEG).
Some studies have suggested that early seizures are associated with haematoma expansion (Vespa., Neurology 2003), worse neurological outcomes (Gilmore., Stroke 2016) or increased mortality. By contrast, other studies have shown no association of acute seizures with long-term mortality and outcome. However, the interpretation of these works is subject to bias because almost all studies were based on clinical detection of seizures only, while it has been shown that most early seizures after ICH are clinically unrecognised and can only be diagnosed with EEG monitoring.
The PEACH trial, a double-blind, randomised, placebo-controlled, showed that clinical and/or electrographic seizures occur in more than 40% of patients with ICH and that Levetiracetam (LVT) is safe and effective in preventing these seizures. However, it remains unclear whether preventing acute seizures might lead to improved functional outcomes after ICH. An adequately powered randomised controlled trial is needed to answer whether primary seizure prophylaxis improves functional outcome in this setting. Answering this question would result in an important change in ICH acute care guidelines, which currently do not recommend primary prophylactic antiseizure treatment. As compared to research in acute ischemic stroke management, fewer clinical trials have been conducted in acute ICH and no effective medical treatments are available in this subset of patients.
The main objective of PEACH 2 is to establish if prophylactic antiseizure therapy with LVT improves functional outcome in adults with acute spontaneous ICH. Functional outcome assessed by the modified Rankin score (mRS score) six months after acute ICH will be compared between patients receiving prophylactic antiseizure therapy with levetiracetam and patients receiving placebo.
The secondary objectives are to examine the effect of prophylactic antiseizure therapy with levetiracetam versus placebo on:
* the number of early and late clinical seizures, on the short term and long term evolution of the neurologic deficit as assessed by the NIHSS, on long term functional outcome (12 months) as assessed by the mRS, on quality of life and cognitive impairment, and on haematoma expansion and mass effect on control brain imaging * the frequency of side effects at 1 and 6 months, pneumonia at 1 month, delirium at 1 month, irritability/aggressivity, anxiety and depression at 1 and 6 months, and all-cause mortality at 1, 6 and 12 months.
580 patients will be recruited over 3 years.
Age ≥ 18 years
Spontaneous (non-traumatic) supratentorial intracerebral haemorrhage diagnosed by brain CT or MRI
Onset of neurologic symptoms within 24 hours
NIHSS score on admission ≤ 25
Intracerebral haemorrhage known or suspected by study investigator to be secondary to trauma, vascular malformation, haemorrhagic transformation of ischaemic stroke, or tumour
Current use of antiseizure drugs or history of epilepsy
Patients with inaugural seizures at the onset of symptoms associated with intracerebral hemorrhage
Patients with QTc prolongation
Parallel
Treatment administration (Levetiracetam or placebo)
DrugTreatment should be initiated within 24 hours of randomisation. It will be administered intravenously for at least 48 hours and then the route of administration will be changed to oral administration at the same dosage after assessment of swallowing function. The treatment period will be 30 days at full dose, followed by a gradual tapering over 2 weeks.
Neuroimaging
RadiationNeuroimaging (brain CT or MRI) will be performed 72h post inclusion
National Institute of Health Stroke Scale (NIHSS)
Diagnostic testNIHSS, a clinician -reported 11-items stroke-specific severity scale, will be administered by a neurologist during all patients' study visits except at visits 1 month and 12 months.
Modified Rankin Scale (mRS)
BehavioralThis questionnaire will be administered 3 time, at inclusion, 6 months and 12 months to measure post-stroke functional status and disability
Euroqol test (EQ-5D-5L)
BehavioralThis self-reported questionnaire will be completed by patients at 6 and 12 months, to assess the multidimensional chronic consequences of stroke on their daily lives
Montreal Cognitive Assessment (MoCA)
BehavioralThis test will be administered by a neurologist at 6 months to assess patients' cognitive impairment
Functional Assessment of Cancer Therapy - Cognitive Function (FACT-Cog)
BehavioralThis self-reported questionnaire will be completed by patients at 6 months, to assess patient's cognitive function (memory, attention, concentration, language, and thinking abilities)
Hospital Anxiety and Depression Scale (HADS)
BehavioralThis questionnaire will be administered at 1 and 6 months to evaluate patients' anxiety and depression
modified Rankin Scale (mRS) score to measure the functional status (death or dependency).
The mRS score will be measured by a certified neurologist, blinded to the patient study group. It categorises disability with reference to pre-stroke activities. mRS is a single-item scale ranging from 0 (no disability) to 5 (severe disability) and 6 (death). Its analysis will be performed by an ordinal logistic regression model with proportional odds and mixed effects. The treatment arm will be introduced in the model as fixed effect and the NIHSS score (≤ 15 vs \>15) will be taken into account as a fixed effect. It will also take into account, as random effect, a random intercept by centre.
Number of clinical seizures
Number of clinical seizures
Number of clinical seizures
Number of clinical seizures
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