Post-stroke seizures: risk factors and management after ischemic stroke

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.

TRIAL REGISTRATION INFORMATION

PROSPERO: CRD42022363844.

Incidence and risk factors of post-stroke seizure among ischemic stroke patients

BACKGROUND

Post-stroke seizure (PSS) increases morbidity and mortality after ischemic stroke, but a comprehensive understanding of its incidence and risk factors is lacking. We report the rate and risk factors of PSS at a single institution.

METHODS

A retrospective cohort study of adult acute ischemic stroke patients between 2018 and 2022 at a comprehensive stroke center was conducted. Patients with a history of seizures, additional stroke during index admission, or death within 7 days of stroke onset were excluded. Early PSS was defined as a new seizure occurring ≤7 days after stroke onset, while late PSS occurred >7 days after stroke onset. Multivariable logistic regression and cox proportional hazard analysis was conducted.

RESULTS

1211 participants met inclusion criteria. Patients were a mean age of 67.82 and were primarily male (58.7 %), white (72.6 %), and non-Hispanic (91.9 %). Incidence of PSS was 8.8 % (n = 106), of which 53.8 % (n = 57) were early and 46.2 % (n = 49) were late. Bivariate analysis identified younger age, diabetes, baseline National Institutes of Health Stroke Scale (NIHSS), Alberta Stroke Program Early Computed Tomography Score ≤5, cortical involvement, and hemorrhagic transformation as significant in the development of PSS. Multivariable cox proportional hazard analysis identified cortical involvement (hazard ratio [HR]: 2.31, 95 % confidence interval [CI] [1,29, 4.14]), NIHSS ≥ 21 (HR: 1.82, 95 % CI [1.02, 3.22]),and younger age (HR: 0.97, 95 % CI [0.96, 0.98]) as significant PSS predictors.

CONCLUSION

PSS occurred in 8.8 % of patients presenting with ischemic stroke. Hemorrhagic transformation, cortical involvement, high NIHSS, and younger age were significant predictors of PSS.

The Association of Epileptic Seizures after Acute Ischemic Stroke with Cerebral Cortical Involvement and Electroencephalographic Changes

Background and objectives: while acute ischemic stroke is the leading cause of epilepsy in the elderly population, data about its risk factors have been conflicting. Therefore, the aim of our study is to determine the association of early and late epileptic seizures after acute ischemic stroke with cerebral cortical involvement and electroencephalographic changes. Materials and methods: a prospective cohort study in the Hospital of the Lithuanian University of Health Sciences Kaunas Clinics Department of Neurology was conducted and enrolled 376 acute ischemic stroke patients. Data about the demographical, clinical, radiological, and encephalographic changes was gathered. Patients were followed for 1 year after stroke and assessed for late ES. Results: the incidence of ES was 4.5%, the incidence of early ES was 2.7% and the incidence of late ES was 2.4%. The occurrence of early ES increased the probability of developing late ES. There was no association between acute cerebral cortical damage and the occurrence of ES, including both early and late ES. However, interictal epileptiform discharges were associated with the occurrence of ES, including both early and late ES.

Third-Generation Antiseizure Medication in the Treatment of Benzodiazepine-Refractory Status Epilepticus in Poststroke Epilepsy: A Retrospective Observational Register-Based Study

BACKGROUND AND OBJECTIVE

Status epilepticus in poststroke epilepsy is a challenging condition because of multiple vascular comorbidities and the advanced age of patients. Data on third-generation antiseizure medication (ASM) in this condition are limited. The aim of this study was to evaluate the efficacy of third-generation ASMs in the second- or third-line therapy of benzodiazepine-refractory status epilepticus in poststroke epilepsy following acute ischemic stroke.

METHODS

Data on the effectiveness of third-generation ASMs in patients with status epilepticus in poststroke epilepsy were gathered from two German Stroke Registries and the Mainz Epilepsy Registry. We included only cases with epilepsy remote to the ischemic event. No patients with acute symptomatic seizures were included. The following third-generation ASMs were included: brivaracetam, lacosamide, eslicarbazepine, perampanel, topiramate, and zonisamide. The assessment of effectiveness was based on seizure freedom within 48 h since the start of therapy with the respective ASM. Seizure freedom was evaluated both clinically (clinical evaluation at least three times per day) and by daily electroencephalogram records.

RESULTS

Of the 138 patients aged 70.8 ± 8.1 years with benzodiazepine-refractory status epilepticus in ischemic poststroke epilepsy, 33 (23.9%) were treated with lacosamide, 24 (17.4%) with brivaracetam, 23 (16.7%) with eslicarbazepine, 21 (15.2%) with perampanel, 20 (14.5%) with topiramate, and 17 (12.3%) with zonisamide. Seizure freedom within 48 h was achieved in 66.7% of patients with lacosamide, 65.2% with eslicarbazepine, 38.1% with perampanel, 37.5% with brivaracetam, 35.0% with topiramate, and 35.3% with zonisamide (p < 0.05 for comparison of lacosamide or eslicarbazepine to other ASMs).

CONCLUSIONS

Based on these data, lacosamide and eslicarbazepine might be more favorable in the treatment of refractory status epilepticus in poststroke epilepsy, when administered as second- or third-line ASMs before anesthesia. Because of the fact that these ASMs share the same mechanism of action (slow inactivation of sodium channels), our findings could motivate further research on the role that this pharmaceutical mechanism of action has in the treatment of poststroke epilepsy.

CLINICAL TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov (NCT05267405).

Mapping Lesion-Related Epilepsy to a Human Brain Network

Importance

It remains unclear why lesions in some locations cause epilepsy while others do not. Identifying the brain regions or networks associated with epilepsy by mapping these lesions could inform prognosis and guide interventions.

Objective

To assess whether lesion locations associated with epilepsy map to specific brain regions and networks.

Design, Setting, and Participants

This case-control study used lesion location and lesion network mapping to identify the brain regions and networks associated with epilepsy in a discovery data set of patients with poststroke epilepsy and control patients with stroke. Patients with stroke lesions and epilepsy (n = 76) or no epilepsy (n = 625) were included. Generalizability to other lesion types was assessed using 4 independent cohorts as validation data sets. The total numbers of patients across all datasets (both discovery and validation datasets) were 347 with epilepsy and 1126 without. Therapeutic relevance was assessed using deep brain stimulation sites that improve seizure control. Data were analyzed from September 2018 through December 2022. All shared patient data were analyzed and included; no patients were excluded.

Main Outcomes and Measures

Epilepsy or no epilepsy.

Results

Lesion locations from 76 patients with poststroke epilepsy (39 [51%] male; mean [SD] age, 61.0 [14.6] years; mean [SD] follow-up, 6.7 [2.0] years) and 625 control patients with stroke (366 [59%] male; mean [SD] age, 62.0 [14.1] years; follow-up range, 3-12 months) were included in the discovery data set. Lesions associated with epilepsy occurred in multiple heterogenous locations spanning different lobes and vascular territories. However, these same lesion locations were part of a specific brain network defined by functional connectivity to the basal ganglia and cerebellum. Findings were validated in 4 independent cohorts including 772 patients with brain lesions (271 [35%] with epilepsy; 515 [67%] male; median [IQR] age, 60 [50-70] years; follow-up range, 3-35 years). Lesion connectivity to this brain network was associated with increased risk of epilepsy after stroke (odds ratio [OR], 2.82; 95% CI, 2.02-4.10; P < .001) and across different lesion types (OR, 2.85; 95% CI, 2.23-3.69; P < .001). Deep brain stimulation site connectivity to this same network was associated with improved seizure control (r, 0.63; P < .001) in 30 patients with drug-resistant epilepsy (21 [70%] male; median [IQR] age, 39 [32-46] years; median [IQR] follow-up, 24 [16-30] months).

Conclusions and Relevance

The findings in this study indicate that lesion-related epilepsy mapped to a human brain network, which could help identify patients at risk of epilepsy after a brain lesion and guide brain stimulation therapies.

Early Epileptic Seizures after Ischemic Stroke: Their Association with Stroke Risk Factors and Stroke Characteristics

Background and Objectives: A growing number of stroke survivors face various stroke complications, including new-onset epileptic seizures (ESs). Post-stroke ESs are divided into early and late ESs based on the time of onset after stroke. Early ESs are associated with worse stroke outcomes, longer hospitalization and an increased risk of late ESs. A variety of risk factors for early ESs are being studied in order to prevent their occurrence. Therefore, we aim to determine the association of early ESs with ischemic stroke risk factors and characteristics. Materials and Methods: A total of 166 patients, treated for ischemic stroke in the Hospital of Lithuanian University of Health Sciences Kaunas Clinics, were enrolled in a prospective cohort study. Initially, data about stroke risk factors, localization, severity and treatment were collected, followed by an observation period of 14 days for early ESs. Results: Early ESs occurred in 11 (6.6%) participants. The probability of early ESs after ischemic stroke among males and females (LogRank = 1.281; p > 0.05), younger (≤65 y) and older (>65 y) participants (LogRank = 0.129; p > 0.05) was the same. The presence of ischemic stroke risk factors, such as atrial fibrillation (LogRank = 0.004; p > 0.05), diabetes mellitus (LogRank = 1.168; p > 0.05) and dyslipidemia (LogRank = 0.092; p > 0.05), did not increase the probability of early ESs. However, participants without a prior history of arterial hypertension (LogRank = 4.453; p < 0.05) were more likely to develop early ESs. Stroke localization (anterior versus posterior) (LogRank = 0.011; p > 0.05), stroke severity (LogRank = 0.395; p > 0.05) and type of treatment (specific versus non-specific) (LogRank = 1.783; p > 0.05) did not affect the probability of early ESs.

Incidence and association of seizures in stroke patients following endovascular treatment: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Post-stroke seizures (PSSs) are some of the most common complications of stroke and are associated with poor outcomes in patients. Endovascular treatment (EVT) is the standard of care for patients with acute ischaemic stroke related large-vessel occlusion. However, whether EVT increases the risk of PSSs remains controversial; the association between PSSs and EVT is poorly understood.

METHODS

PubMed, Embase and the Cochrane Library were searched for relevant studies published from 1995 to 6 December 2021. The overall incidence of PSSs in patients treated with EVT and the separate incidence for all included studies in each subgroup, stratified by the type of treatment or time of onset, were calculated. The pooled odds ratio and confidence interval were calculated to quantify the effects of EVT on PSS occurrence.

RESULTS

In all, 946 studies were screened and 16 articles were included, with a total sample size of 12,664 patients; 7836 patients received EVT, of whom 460 had PSS. The pooled incidence of PSS after EVT was 5.8%, which was similar to patients treated with mechanical thrombectomy (5.3%), intra-arterial thrombolysis (6.8%) or bridging therapy (5.4%). The cumulative incidence of post-stroke epilepsy (6.0%) was almost twice that of acute symptomatic seizures (3.6%). The pooled odds ratio for the relationship between EVT and PSS was 1.91 (95% confidence interval 0.98-3.73).

CONCLUSIONS

The cumulative incidence of stroke patients treated with EVT who developed seizures was 5.8%, and EVT was non-significantly associated with the occurrence of seizures after stroke.

Poststroke Seizure and Epilepsy: A Review of Incidence, Risk Factors, Diagnosis, Pathophysiology, and Pharmacological Therapies

Stroke is the most common cause of epilepsy and ultimately leads to a decrease in the quality of life of those affected. Ischemic and hemorrhagic strokes can both lead to poststroke epilepsy (PSE). Significant risk factors for PSE include age < 65age less than 65 years, stroke severity measured by the National Institutes of Health Stroke Scale (NIHSS), cortical involvement, and genetic factors such as TRPM6 polymorphism. The diagnosis of PSE is made by using imaging modalities, blood biomarkers, and prognostic criteria. Electroencephalography (EEG) is currently the gold standard to diagnose PSE, while new combinations of modalities are being tested to increase diagnostic specificity. This literature review uncovers a newly found mechanism for the pathology of poststroke epilepsy. The pathogenesis of early-onset and late-onset is characterized by sequelae of neuronal cellular hypoxia and disruption of the blood-brain barrier, respectively. Interleukin-6 is responsible for increasing the activity of glial cells, causing gliosis and hyperexcitability of neurons. Epinephrine, high-mobility group protein B1, downregulation of CD32, and upregulation of HLA-DR impact the pathology of poststroke epilepsy by inhibiting the normal neuronal immune response. Decreased levels of neuropeptide Y, a neurotransmitter, act through multiple unique mechanisms, such as inhibiting intracellular Ca²⁺ accumulation and acting as an anti-inflammatory, also implemented in the worsening progression of poststroke epilepsy. Additionally, CA1 hippocampal resonant neurons that increase theta oscillation are associated with poststroke epilepsy. Hypertensive small vessel disease may also have an implication in the temporal lobe epilepsy by causing occult microinfarctions. Furthermore, this review highlights the potential use of statins as primary prophylaxis against PSE, with multiple studies demonstrating a reduction in incidence using statins alone, statins in combination with antiepileptic drugs (AEDs), and statins with aspirin. The evidence strongly suggests that the second generation AEDs are a superior treatment method for PSE. Data from numerous studies demonstrate their relative lack of significant drug interactions, increased tolerability, and potential superiority in maintaining seizure-free status.