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Tanaka T, Ihara M, Fukuma K, Mishra NK, Koepp MJ, Guekht A, Ikeda A. Pathophysiology, Diagnosis, Prognosis, and Prevention of Poststroke Epilepsy: Clinical and Research Implications. Neurology 2024; 102:e209450. [PMID: 38759128 DOI: 10.1212/wnl.0000000000209450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024] Open
Abstract
Poststroke epilepsy (PSE) is associated with higher mortality and poor functional and cognitive outcomes in patients with stroke. With the remarkable development of acute stroke treatment, there is a growing number of survivors with PSE. Although approximately 10% of patients with stroke develop PSE, given the significant burden of stroke worldwide, PSE is a significant problem in stroke survivors. Therefore, the attention of health policymakers and significant funding are required to promote PSE prevention research. The current PSE definition includes unprovoked seizures occurring more than 7 days after stroke onset, given the high recurrence risks of seizures. However, the pathologic cascade of stroke is not uniform, indicating the need for a tissue-based approach rather than a time-based one to distinguish early seizures from late seizures. EEG is a commonly used tool in the diagnostic work-up of PSE. EEG findings during the acute phase of stroke can potentially stratify the risk of subsequent seizures and predict the development of poststroke epileptogenesis. Recent reports suggest that cortical superficial siderosis, which may be involved in epileptogenesis, is a promising marker for PSE. By incorporating such markers, future risk-scoring models could guide treatment strategies, particularly for the primary prophylaxis of PSE. To date, drugs that prevent poststroke epileptogenesis are lacking. The primary challenge involves the substantial cost burden due to the difficulty of reliably enrolling patients who develop PSE. There is, therefore, a critical need to determine reliable biomarkers for PSE. The goal is to be able to use them for trial enrichment and as a surrogate outcome measure for epileptogenesis. Moreover, seizure prophylaxis is essential to prevent functional and cognitive decline in stroke survivors. Further elucidation of factors that contribute to poststroke epileptogenesis is eagerly awaited. Meanwhile, the regimen of antiseizure medications should be based on individual cardiovascular risk, psychosomatic comorbidities, and concomitant medications. This review summarizes the current understanding of poststroke epileptogenesis, its risks, prognostic models, prophylaxis, and strategies for secondary prevention of seizures and suggests strategies to advance research on PSE.
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Affiliation(s)
- Tomotaka Tanaka
- From the Department of Neurology (T.T., M.I., K.F.), National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Neurology (N.K.M.), Yale University School of Medicine, New Haven, CT; Department of Clinical & Experimental Epilepsy (M.J.K.), UCL Queen Square Institute of Neurology, London, United Kingdom; Moscow Research and Clinical Center for Neuropsychiatry (A.G.), Pirogov Russian National Research Medical University, Russia; and Department of Epilepsy, Movement Disorders and Physiology (A.I.), Kyoto University Graduate School of Medicine, Japan
| | - Masafumi Ihara
- From the Department of Neurology (T.T., M.I., K.F.), National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Neurology (N.K.M.), Yale University School of Medicine, New Haven, CT; Department of Clinical & Experimental Epilepsy (M.J.K.), UCL Queen Square Institute of Neurology, London, United Kingdom; Moscow Research and Clinical Center for Neuropsychiatry (A.G.), Pirogov Russian National Research Medical University, Russia; and Department of Epilepsy, Movement Disorders and Physiology (A.I.), Kyoto University Graduate School of Medicine, Japan
| | - Kazuki Fukuma
- From the Department of Neurology (T.T., M.I., K.F.), National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Neurology (N.K.M.), Yale University School of Medicine, New Haven, CT; Department of Clinical & Experimental Epilepsy (M.J.K.), UCL Queen Square Institute of Neurology, London, United Kingdom; Moscow Research and Clinical Center for Neuropsychiatry (A.G.), Pirogov Russian National Research Medical University, Russia; and Department of Epilepsy, Movement Disorders and Physiology (A.I.), Kyoto University Graduate School of Medicine, Japan
| | - Nishant K Mishra
- From the Department of Neurology (T.T., M.I., K.F.), National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Neurology (N.K.M.), Yale University School of Medicine, New Haven, CT; Department of Clinical & Experimental Epilepsy (M.J.K.), UCL Queen Square Institute of Neurology, London, United Kingdom; Moscow Research and Clinical Center for Neuropsychiatry (A.G.), Pirogov Russian National Research Medical University, Russia; and Department of Epilepsy, Movement Disorders and Physiology (A.I.), Kyoto University Graduate School of Medicine, Japan
| | - Matthias J Koepp
- From the Department of Neurology (T.T., M.I., K.F.), National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Neurology (N.K.M.), Yale University School of Medicine, New Haven, CT; Department of Clinical & Experimental Epilepsy (M.J.K.), UCL Queen Square Institute of Neurology, London, United Kingdom; Moscow Research and Clinical Center for Neuropsychiatry (A.G.), Pirogov Russian National Research Medical University, Russia; and Department of Epilepsy, Movement Disorders and Physiology (A.I.), Kyoto University Graduate School of Medicine, Japan
| | - Alla Guekht
- From the Department of Neurology (T.T., M.I., K.F.), National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Neurology (N.K.M.), Yale University School of Medicine, New Haven, CT; Department of Clinical & Experimental Epilepsy (M.J.K.), UCL Queen Square Institute of Neurology, London, United Kingdom; Moscow Research and Clinical Center for Neuropsychiatry (A.G.), Pirogov Russian National Research Medical University, Russia; and Department of Epilepsy, Movement Disorders and Physiology (A.I.), Kyoto University Graduate School of Medicine, Japan
| | - Akio Ikeda
- From the Department of Neurology (T.T., M.I., K.F.), National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Neurology (N.K.M.), Yale University School of Medicine, New Haven, CT; Department of Clinical & Experimental Epilepsy (M.J.K.), UCL Queen Square Institute of Neurology, London, United Kingdom; Moscow Research and Clinical Center for Neuropsychiatry (A.G.), Pirogov Russian National Research Medical University, Russia; and Department of Epilepsy, Movement Disorders and Physiology (A.I.), Kyoto University Graduate School of Medicine, Japan
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Koepp MJ, Trinka E, Mah Y, Bentes C, Knake S, Gigli GL, Serratosa JM, Zelano J, Magalhães LM, Pereira A, Moreira J, Soares‐da‐Silva P. Antiepileptogenesis after stroke-trials and tribulations: Methodological challenges and recruitment results of a Phase II study with eslicarbazepine acetate. Epilepsia Open 2023; 8:1190-1201. [PMID: 36944588 PMCID: PMC10472381 DOI: 10.1002/epi4.12735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/07/2023] [Indexed: 03/23/2023] Open
Abstract
There is currently no evidence to support the use of antiseizure medications to prevent unprovoked seizures following stroke. Experimental animal models suggested a potential antiepileptogenic effect for eslicarbazepine acetate (ESL), and a Phase II, multicenter, randomized, double-blind, placebo-controlled study was designed to test this hypothesis and assess whether ESL treatment for 1 month can prevent unprovoked seizures following stroke. We outline the design and status of this antiepileptogenesis study, and discuss the challenges encountered in its execution to date. Patients at high risk of developing unprovoked seizures after acute intracerebral hemorrhage or acute ischemic stroke were randomized to receive ESL 800 mg/d or placebo, initiated within 120 hours after primary stroke occurrence. Treatment continued until Day 30, then tapered off. Patients could receive all necessary therapies for stroke treatment according to clinical practice guidelines and standard of care, and are being followed up for 18 months. The primary efficacy endpoint is the occurrence of a first unprovoked seizure within 6 months after randomization ("failure rate"). Secondary efficacy assessments include the occurrence of a first unprovoked seizure during 12 months after randomization and during the entire study; functional outcomes (Barthel Index original 10-item version; National Institutes of Health Stroke Scale); post-stroke depression (Patient Health Questionnaire-9; PHQ-9); and overall survival. Safety assessments include the evaluation of treatment-emergent adverse events; laboratory parameters; vital signs; electrocardiogram; suicidal ideation and behavior (PHQ-9 question 9). The protocol aimed to randomize approximately 200 patients (1:1), recruited from 21 sites in seven European countries and Israel. Despite the challenges encountered, particularly during the COVID-19 pandemic, the study progressed and included a remarkable number of patients, with 129 screened and 125 randomized. Recruitment was stopped after 30 months, the first patient entered in May 2019, and the study is ongoing and following up on patients according to the Clinical Trial Protocol.
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Affiliation(s)
- Matthias J. Koepp
- UCL Queen Square Institute of NeurologyLondonUK
- National Hospital for Neurology and NeurosurgeryLondonUK
| | - Eugen Trinka
- Department of NeurologyChristian‐Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Member of EpiCARESalzburgAustria
- Neuroscience Institute, Christian‐Doppler University HospitalParacelsus Medical University, Centre for Cognitive NeuroscienceSalzburgAustria
- Institute of Public Health, Medical Decision‐Making and HTAUMIT – Private University for Health SciencesMedical Informatics and TechnologyHall in TyrolAustria
| | - Yee‐Haur Mah
- King's College Hospital NHS Foundation TrustLondonUK
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
| | - Carla Bentes
- Reference Centre for Refractory Epilepsies (Member of EpiCARE)Hospital de Santa Maria‐CHULNLisbonPortugal
- Department of Neuroscience and Mental Health (Neurology)Hospital de Santa Maria‐CHULNLisbonPortugal
- Centro de Estudos Egas MonizFaculdade de Medicina da Universidade de LisboaLisbonPortugal
| | - Susanne Knake
- Department of Neurology, Epilepsy Centre HessenPhilipps‐University MarburgMarburgGermany
| | - Gian Luigi Gigli
- Clinical Neurology Unit, Department of Medicine (DAME)University of UdineUdineItaly
| | - José M. Serratosa
- Department of Neurology and Laboratory of Neurology, Fundación Instituto de Investigación Sanitaria‐Fundación Jiménez DíazAutónoma UniversityMadridSpain
- Centro de Investigacion Biomedica en Red de Enfermedades Raras (CIBERER)MadridSpain
| | - Johan Zelano
- Institute of Neuroscience and Physiology, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Wallenberg Centre for Molecular and Translational MedicineUniversity of GothenburgGothenburgSweden
- Department of NeurologySahlgrenska University HospitalGothenburgSweden
| | | | | | | | - Patrício Soares‐da‐Silva
- Bial—Portela & Cª, S.A.CoronadoPortugal
- Department of BiomedicinePharmacology and Therapeutics Unit, Faculty of MedicineUniversity PortoPortoPortugal
- MedInUP—Center for Drug Discovery and Innovative MedicinesUniversity PortoPortoPortugal
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Moura LM, Donahue MA, Yan Z, Smith LH, Hsu J, Newhouse JP, Lee S, Haneuse S, Hernandez-Diaz S, Blacker D. Comparative Effectiveness and Safety of Seizure Prophylaxis Among Adults After Acute Ischemic Stroke. Stroke 2023; 54:527-536. [PMID: 36544249 PMCID: PMC9870933 DOI: 10.1161/strokeaha.122.039946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 11/18/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Older adults occasionally receive seizure prophylaxis in an acute ischemic stroke (AIS) setting, despite safety concerns. There are no trial data available about the net impact of early seizure prophylaxis on post-AIS survival. METHODS Using a stroke registry (American Heart Association's Get With The Guidelines) individually linked to electronic health records, we examined the effect of initiating seizure prophylaxis (ie, epilepsy-specific antiseizure drugs) within 7 days of an AIS admission versus not initiating in patients ≥65 years admitted for a new, nonsevere AIS (National Institutes of Health Stroke Severity score ≤20) between 2014 and 2021 with no recorded use of epilepsy-specific antiseizure drugs in the previous 3 months. We addressed confounding by using inverse-probability weights. We performed standardization accounting for pertinent clinical and health care factors (eg, National Institutes of Health Stroke Severity scale, prescription counts, seizure-like events). RESULTS The study sample included 151 patients who received antiseizure drugs and 3020 who did not. The crude 30-day mortality risks were 219 deaths per 1000 patients among epilepsy-specific antiseizure drugs initiators and 120 deaths per 1000 among noninitiators. After standardization, the estimated mortality was 251 (95% CI, 190-307) deaths per 1000 among initiators and 120 (95% CI, 86-144) deaths per 1000 among noninitiators, corresponding to a risk difference of 131 (95% CI, 65-200) excess deaths per 1000 patients. In the prespecified subgroup analyses, the risk difference was 52 (95% CI, 11-72) among patients with minor AIS and 138 (95% CI, 52-222) among moderate-to-severe AIS patients. Similarly, the risk differences were 86 (95% CI, 18-118) and 157 (95% CI, 57-219) among patients aged 65 to 74 years and ≥75 years, respectively. CONCLUSIONS There was a higher risk of 30-day mortality associated with initiating versus not initiating seizure prophylaxis within 7 days post-AIS. This study does not support the role of seizure prophylaxis in reducing 30-day poststroke mortality.
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Affiliation(s)
- Lidia M.V.R. Moura
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Maria A. Donahue
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Zhiyu Yan
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Louisa H. Smith
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - John Hsu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Joseph P. Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Kennedy School, Cambridge, Massachusetts
| | - Schwamm Lee
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Sebastien Haneuse
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Deborah Blacker
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
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Håkansson S, Zelano J. Big data analysis of ASM retention rates and expert ASM algorithm: a comparative study. Epilepsia 2022; 63:1553-1562. [PMID: 35325474 PMCID: PMC9321965 DOI: 10.1111/epi.17235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/23/2022] [Accepted: 03/23/2022] [Indexed: 11/29/2022]
Abstract
Objective Only 50% of patients with new‐onset epilepsy achieve seizure freedom with their first antiseizure medication (ASM). A growing body of data illustrates the complexity of predicting ASM response and tolerability, which is influenced by age, sex, and comorbidities. Randomized data with sufficient resolution for personalized medicine are unlikely to emerge. Two potential facilitators of ASM selection are big data using real‐world retention rates or algorithms based on expert opinion. We asked how these methods compare in adult‐onset focal epilepsy. Methods ASM retention rates were determined by cross‐referencing data from comprehensive Swedish registers for 37 643 individuals, with identified comorbidities. Eight fictive cases were created and expert advice was collected from the algorithm Epipick. We compared Epipick suggestions in representative patient subgroups, and determined whether ranking based on retention rate reflected expert advice. Results The Epipick algorithm suggested six ASM alternatives for younger patients and three ASM alternatives for older patients. In the real‐world data, retention rates for the ASMs ranked as best options by Epipick were high; 65%–72% for young patients and 71%–84% for older patients. The lowest retention rate for Epipick suggestions was 42%–56% in younger cases, and 70%–80% in older cases. The ASM with the best retention rate was generally recommended by Epipick. Significance We found a large overlap between expert advice and real‐world retention rates. Notably, Epipick did suggest some ASMs with more modest retention rates. Conversely, clearly inappropriate ASMs (not recommended by Epipick) had high retention rates in some cases, showing that decision systems should not rely indiscriminately on retention rates alone. In future clinical decision support systems, expert opinion and real‐world retention rates could work synergistically.
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Affiliation(s)
- Samuel Håkansson
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Wallenberg Center for Molecular and Translational Medicine, Gothenburg University, Gothenburg, Sweden
| | - Johan Zelano
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Wallenberg Center for Molecular and Translational Medicine, Gothenburg University, Gothenburg, Sweden
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5
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Eastman CL, Fender JS, Klein P, D'Ambrosio R. Therapeutic Effects of Time-Limited Treatment with Brivaracetam on Posttraumatic Epilepsy after Fluid Percussion Injury in the Rat. J Pharmacol Exp Ther 2021; 379:310-323. [PMID: 34593559 DOI: 10.1124/jpet.121.000585] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 09/28/2021] [Indexed: 11/22/2022] Open
Abstract
Mounting evidence suggests the synaptic vesicle glycoprotein 2A (SV2A) targeted by levetiracetam may contribute to epileptogenesis. Levetiracetam has shown anti-inflammatory, antioxidant, neuroprotective, and possible antiepileptogenic effects in brain injury and seizure/epilepsy models, and a phase 2 study has signaled a possible clinical antiepileptogenic effect. Brivaracetam shows greater affinity and specificity for SV2A than levetiracetam and broader preclinical antiseizure effects. Thus, we assessed the antiepileptogenic/disease-modifying potential of brivaracetam in an etiologically realistic rat posttraumatic epilepsy model optimized for efficient drug testing. Brivaracetam delivery protocols were designed to maintain clinical moderate-to-high plasma levels in young (5-week-old) male Sprague-Dawley rats for 4 weeks. Treatment protocols were rapidly screened in 4-week experiments using small groups of animals to ensure against rigorous testing of futile treatment protocols. The antiepileptogenic effects of brivaracetam treatment initiated 30 minutes, 4 hours, and 8 hours after rostral parasagittal fluid percussion injury (rpFPI) were then compared with vehicle-treated controls in a fully powered blind and randomized 16-week validation. Seizures were evaluated by video-electrocorticography using a 5-electrode epidural montage. Endpoint measures included incidence, frequency, duration, and spread of seizures. Group sizes and recording durations were supported by published power analyses. Three months after treatment ended, rats treated with brivaracetam starting at 4 hours post-FPI (the best-performing protocol) experienced a 38% decrease in overall incidence of seizures, 59% decrease in seizure frequency, 67% decrease in time spent seizing, and a 45% decrease in the proportion of spreading seizures that was independent of duration-based seizure definition. Thus, brivaracetam shows both antiepileptogenic and disease-modifying properties after rpFPI. SIGNIFICANCE STATEMENT: The rpFPI model, which likely incorporates epileptogenic mechanisms operating after human head injury, can be used to efficiently screen investigational treatment protocols and assess antiepileptogenic/disease-modifying effects. Our studies 1) support a role for SV2A in epileptogenesis, 2) suggest that brivaracetam and other drugs targeting SV2A should be considered for human clinical trials of prevention of post-traumatic epilepsy after head injury, and 3) provide data to inform the design of treatment protocols for clinical trials.
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Affiliation(s)
- Clifford L Eastman
- Department of Neurological Surgery, University of Washington, Seattle, Washington (C.L.E., J.S.F., R.D.); and Mid-Atlantic Epilepsy and Sleep Center, Bethesda, Maryland (P.K.)
| | - Jason S Fender
- Department of Neurological Surgery, University of Washington, Seattle, Washington (C.L.E., J.S.F., R.D.); and Mid-Atlantic Epilepsy and Sleep Center, Bethesda, Maryland (P.K.)
| | - Pavel Klein
- Department of Neurological Surgery, University of Washington, Seattle, Washington (C.L.E., J.S.F., R.D.); and Mid-Atlantic Epilepsy and Sleep Center, Bethesda, Maryland (P.K.)
| | - Raimondo D'Ambrosio
- Department of Neurological Surgery, University of Washington, Seattle, Washington (C.L.E., J.S.F., R.D.); and Mid-Atlantic Epilepsy and Sleep Center, Bethesda, Maryland (P.K.)
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Nicolo JP, Chen Z, Moffat B, Wright DK, Sinclair B, Glarin R, Neal A, Thijs V, Seneviratne U, Yan B, Cloud G, O'Brien TJ, Kwan P. Study protocol for a phase II randomised, double-blind, placebo-controlled trial of perampanel as an antiepileptogenic treatment following acute stroke. BMJ Open 2021; 11:e043488. [PMID: 33972334 PMCID: PMC8112439 DOI: 10.1136/bmjopen-2020-043488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Stroke is a common cause of epilepsy that may be mediated via glutamate dysregulation. There is currently no evidence to support the use of antiseizure medications as primary prevention against poststroke epilepsy. Perampanel has a unique antiglutamatergic mechanism of action and may have antiepileptogenic properties. This study aims to evaluate the efficacy and safety of perampanel as an antiepileptogenic treatment in patients at high risk of poststroke epilepsy. METHODS AND ANALYSIS Up to 328 patients with cortical ischaemic stroke or lobar haemorrhage will be enrolled, and receive their first treatment within 7 days of stroke onset. Patients will be randomised (1:1) to receive perampanel (titrated to 6 mg daily over 4 weeks) or matching placebo, stratified by stroke subtype (ischaemic or haemorrhagic). Treatment will be continued for 12 weeks after titration. 7T MRI will be performed at baseline for quantification of cerebral glutamate by magnetic resonance spectroscopy and glutamate chemical exchange saturation transfer imaging. Blood will be collected for measurement of plasma glutamate levels. Participants will be followed up for 52 weeks after randomisation.The primary study outcome will be the proportion of participants in each group free of late (more than 7 days after stroke onset) poststroke seizures by the end of the 12-month study period, analysed by Fisher's exact test. Secondary outcomes will include time to first seizure, time to treatment withdrawal and 3-month modified Rankin Scale score. Quality of life, cognitive function, mood and adverse events will be assessed by standardised questionnaires. Exploratory outcomes will include correlation between cerebral and plasma glutamate concentration and stroke and seizure outcomes. ETHICS AND DISSEMINATION This study was approved by the Alfred Health Human Research Ethics Committee (HREC No 44366, Reference 287/18). TRIAL REGISTRATION NUMBER ACTRN12618001984280; Pre-results.
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Affiliation(s)
- John-Paul Nicolo
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Zhibin Chen
- Department of Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Bradford Moffat
- Melbourne Node of the National Imaging Facility, Department of Radiology, University of Melbourne, Parkville, Victoria, Australia
| | - David K Wright
- Department of Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Benjamin Sinclair
- Department of Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Rebecca Glarin
- Melbourne Node of the National Imaging Facility, Department of Radiology, University of Melbourne, Parkville, Victoria, Australia
| | - Andrew Neal
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health-Austin Campus, Heidelberg, Victoria, Australia
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
| | - Udaya Seneviratne
- Department of Neuroscience, Monash University, Clayton, Victoria, Australia
- Department of Neurology, Monash Medical Centre, Clayton, Victoria, Australia
| | - Bernard Yan
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Geoffrey Cloud
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Terence J O'Brien
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Patrick Kwan
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
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Steffel J, Collins R, Antz M, Cornu P, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Vanassche T, Potpara T, Camm AJ, Heidbüchel H, Lip GYH, Deneke T, Dagres N, Boriani G, Chao TF, Choi EK, Hills MT, Santos IDS, Lane DA, Atar D, Joung B, Cole OM, Field M. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace 2021; 23:1612-1676. [PMID: 33895845 DOI: 10.1093/europace/euab065] [Citation(s) in RCA: 411] [Impact Index Per Article: 137.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Jan Steffel
- Department of Cardiology, Division of Electrophysiology, University Heart Center Zurich, Switzerland
| | - Ronan Collins
- Age-Related Health Care, Tallaght University Hospital / Department of Gerontology Trinity College, Dublin, Ireland
| | - Matthias Antz
- Department of Electrophysiology, Hospital Braunschweig, Braunschweig, Germany
| | - Pieter Cornu
- Faculty of Medicine and Pharmacy, Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lien Desteghe
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK
| | - Hein Heidbüchel
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan & Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Itamar de Souza Santos
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,Departamento de Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Boyoung Joung
- Yonsei University College of Medicine, Cardiology Department, Seoul, Republic of Korea
| | - Oana Maria Cole
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Field
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
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8
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Galovic M, Ferreira-Atuesta C, Abraira L, Döhler N, Sinka L, Brigo F, Bentes C, Zelano J, Koepp MJ. Seizures and Epilepsy After Stroke: Epidemiology, Biomarkers and Management. Drugs Aging 2021; 38:285-299. [PMID: 33619704 PMCID: PMC8007525 DOI: 10.1007/s40266-021-00837-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2021] [Indexed: 12/14/2022]
Abstract
Stroke is the leading cause of seizures and epilepsy in older adults. Patients who have larger and more severe strokes involving the cortex, are younger, and have acute symptomatic seizures and intracerebral haemorrhage are at highest risk of developing post-stroke epilepsy. Prognostic models, including the SeLECT and CAVE scores, help gauge the risk of epileptogenesis. Early electroencephalogram and blood-based biomarkers can provide information additional to the clinical risk factors of post-stroke epilepsy. The management of acute versus remote symptomatic seizures after stroke is markedly different. The choice of an ideal antiseizure medication should not only rely on efficacy but also consider adverse effects, altered pharmacodynamics in older adults, and the influence on the underlying vascular co-morbidity. Drug-drug interactions, particularly those between antiseizure medications and anticoagulants or antiplatelets, also influence treatment decisions. In this review, we describe the epidemiology, risk factors, biomarkers, and management of seizures after an ischaemic or haemorrhagic stroke. We discuss the special considerations required for the treatment of post-stroke epilepsy due to the age, co-morbidities, co-medication, and vulnerability of stroke survivors.
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Affiliation(s)
- Marian Galovic
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland.
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK.
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK.
| | - Carolina Ferreira-Atuesta
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Laura Abraira
- Epilepsy Unit, Department of Neurology, Vall d'Hebron Hospital Universitari, Barcelona, Spain
- Universitat Autonoma de Barcelona, Bellaterra, Spain
| | - Nico Döhler
- Specialist Clinic for Neurorehabilitation, Kliniken Beelitz, Beelitz-Heilstätten, Germany
| | - Lucia Sinka
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland
| | - Francesco Brigo
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Italy
| | - Carla Bentes
- Department of Neurosciences and Mental Health (Neurology), Hospital de Santa Maria-CHLN, Lisboa, Portugal
| | - Johan Zelano
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Matthias J Koepp
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK
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9
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van Tuijl JH, van Raak EPM, van Oostenbrugge RJ, Aldenkamp AP, Rouhl RPW. Treatment with Diazepam in Acute Stroke Prevents Poststroke Seizures: A Substudy of the EGASIS Trial. Cerebrovasc Dis 2021; 50:216-221. [PMID: 33465768 DOI: 10.1159/000512799] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 09/29/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The frequency of seizures after stroke is high, with a severe impact on the quality of life. However, little is known about their prevention. Therefore, we investigated whether early administration of diazepam prevents the development of seizures in acute stroke patients. METHODS We performed a substudy of the EGASIS trial, a multicenter double-blind, randomized trial in which acute stroke patients were treated with diazepam or placebo for 3 days. Follow-up was after 2 weeks and 3 months. The occurrence of seizures was registered prospectively as one of the prespecified secondary outcomes. RESULTS 784 EGASIS patients were eligible for this substudy (389 treated with diazepam [49.6%] and 395 treated with placebo [50.4%]). Seizures were reported in 19 patients (2.4% of the total patient group). Seizures occurred less frequently in patients treated with diazepam (1.5 vs. 3.3% in the placebo group); however, this difference was only statistically significant in patients with a cortical anterior circulation infarction (0.9% in the diazepam group vs. 4.6% in the placebo group, incidence rate ratio 0.20, 95% CI: 0.05-0.78, p = 0.02, NNT = 27). CONCLUSION We found that a 3-day treatment with diazepam after acute cortical anterior circulation stroke prevents the occurrence of seizures in the first 3 months following stroke.
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Affiliation(s)
- Julia H van Tuijl
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Neurology, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - Elisabeth P M van Raak
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands.,School for Mental Health & Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Albert P Aldenkamp
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands.,School for Mental Health & Neuroscience, Maastricht University, Maastricht, The Netherlands.,Academic Center for Epileptology Kempenhaeghe and Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rob P W Rouhl
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands, .,School for Mental Health & Neuroscience, Maastricht University, Maastricht, The Netherlands, .,Academic Center for Epileptology Kempenhaeghe and Maastricht University Medical Center, Maastricht, The Netherlands,
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10
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Leo A, De Caro C, Nesci V, Tallarico M, De Sarro G, Russo E, Citraro R. Modeling poststroke epilepsy and preclinical development of drugs for poststroke epilepsy. Epilepsy Behav 2020; 104:106472. [PMID: 31427267 DOI: 10.1016/j.yebeh.2019.106472] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 07/23/2019] [Accepted: 07/26/2019] [Indexed: 12/21/2022]
Abstract
Stroke is a severe clinical issue for global public health, representing the third leading cause of death and a major cause of disability in developed countries. Progresses in the pharmacological treatment of the acute stroke have given rise to a significant decrease in its mortality rate. However, as a result, there has been an increasing number of stroke survivors living with disability worldwide. Poststroke epilepsy (PSE) is a common clinical complication following stroke. Seizures can arise in close temporal association with stroke damage and/or after a variably longer interval. Overall, PSE have a good prognosis; in fact, its responding rate to antiepileptic drugs (AEDs) is higher than other types of epilepsy. However, regarding pharmacological treatment, some issues are still unresolved. To this aim, a deeper understanding of mechanisms underlying the transformation of infarcted tissue into an epileptic focus or better from a nonepileptic brain to an epileptic brain is also mandatory for PSE. However, studying epileptogenesis in patients with PSE clearly has several limitations and difficulties; therefore, modeling PSE is crucial. Until now, different experimental models have been used to study the etiopathology of cerebrovascular stroke with or without infarction, but few studies focused on poststroke epileptogenesis and PSE. In this review, we show a brief overview on the features emerging from preclinical research into experimental PSE, which could affect the discovery of biomarkers and therapy strategies for poststroke epileptogenesis. This article is part of the Special Issue "Seizures & Stroke".
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Affiliation(s)
- Antonio Leo
- Science of Health Department, School of Medicine, University "Magna Graecia" of Catanzaro, Viale Europa e Germaneto, 88100 Catanzaro, Italy
| | - Carmen De Caro
- Science of Health Department, School of Medicine, University "Magna Graecia" of Catanzaro, Viale Europa e Germaneto, 88100 Catanzaro, Italy
| | - Valentina Nesci
- Science of Health Department, School of Medicine, University "Magna Graecia" of Catanzaro, Viale Europa e Germaneto, 88100 Catanzaro, Italy
| | - Martina Tallarico
- Science of Health Department, School of Medicine, University "Magna Graecia" of Catanzaro, Viale Europa e Germaneto, 88100 Catanzaro, Italy
| | - Giovambattista De Sarro
- Science of Health Department, School of Medicine, University "Magna Graecia" of Catanzaro, Viale Europa e Germaneto, 88100 Catanzaro, Italy
| | - Emilio Russo
- Science of Health Department, School of Medicine, University "Magna Graecia" of Catanzaro, Viale Europa e Germaneto, 88100 Catanzaro, Italy.
| | - Rita Citraro
- Science of Health Department, School of Medicine, University "Magna Graecia" of Catanzaro, Viale Europa e Germaneto, 88100 Catanzaro, Italy
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11
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Nicolo JP, O'Brien TJ, Kwan P. Role of cerebral glutamate in post-stroke epileptogenesis. NEUROIMAGE-CLINICAL 2019; 24:102069. [PMID: 31795040 PMCID: PMC6883323 DOI: 10.1016/j.nicl.2019.102069] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/13/2019] [Accepted: 11/03/2019] [Indexed: 01/17/2023]
Abstract
Stroke is one of the most important causes of acquired epilepsy in the adult population. While factors such as cortical involvement and haemorrhage have been associated with increased seizure risk, the mechanisms underlying the development of epilepsy after stroke remain unclear. One hypothesised mechanism is an excitotoxic effect of abnormal glutamate release following a stroke. Cerebral extracellular glutamate levels are known to rise in the setting of acute stroke, and numerous studies have implicated glutamate in the pathogenesis of seizures and epilepsy, both through direct measurement of glutamate from the epileptic brain and by analysis of receptors and transporters central to glutamate homeostasis. While experimental evidence suggests the cellular injury induced by glutamate exposure may lead to development of an epileptic phenotype, there is little direct data linking the rise in glutamate during stroke with the later development of epilepsy. Clinical research in this field has been hampered by the lack of non-invasive methods to measure cerebral glutamate. However, with the increasing availability of 7T MRI technology, Magnetic Resonance Spectroscopy is able to better resolve glutamate from other chemical species at this field strength, and Glutamate Chemical Exchange Saturation Transfer (GluCEST) imaging has been applied to localise epileptic foci in non-lesional focal epilepsy. This review outlines the evidence implicating a pivotal role for cerebral glutamate in the development of post-stroke epilepsy, and exploring the role of MRI in studying glutamate as a biomarker and therefore its suitability as a molecular target for anti-epileptogenic therapies. We hypothesise that the rise in glutamate levels in the setting of acute stroke is a clinically relevant biomarker for the development of post-stroke epilepsy.
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Affiliation(s)
- John-Paul Nicolo
- Department of Neurology, Royal Melbourne Hospital, 300 Grattan Street Parkville Victoria Australia; Department of Neurology, Alfred Hospital, 55 Commercial Road, Melbourne Victoria Australia.
| | - Terence J O'Brien
- Department of Neuroscience, Monash University, Alfred Hospital, 55 Commercial Road, Melbourne Victoria Australia; Department of Medicine (The Royal Melbourne Hospital), The University of Melbourne, Royal Parade, Parkville Victoria Australia.
| | - Patrick Kwan
- Department of Neurology, Royal Melbourne Hospital, 300 Grattan Street Parkville Victoria Australia; Department of Neuroscience, Monash University, Alfred Hospital, 55 Commercial Road, Melbourne Victoria Australia.
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12
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Feyissa AM, Hasan TF, Meschia JF. Stroke-related epilepsy. Eur J Neurol 2018; 26:18-e3. [PMID: 30320425 DOI: 10.1111/ene.13813] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 09/19/2018] [Indexed: 01/16/2023]
Abstract
Stroke is the cause of about 10% of all epilepsy and 55% of newly diagnosed seizures among the elderly. Although recent advances in acute stroke therapy have improved longevity, there has been a consequent rise in the prevalence of stroke-related epilepsy (STRE). Many clinical studies make a distinction between early (within 7 days of onset of stroke) and late (beyond 7 days of onset of stroke) seizures based on presumed pathophysiological differences. Although early seizures are thought to be the consequence of local metabolic disturbances without altered neuronal networks, late seizures are thought to occur when the brain has acquired a predisposition for seizures. Overall, STRE has a good prognosis, being well controlled by antiepileptic drugs. However, up to 25% of cases become drug resistant. STRE can also result in increased morbidity, longer hospitalization, greater disability at discharge and greater resource utilization. Additional controlled trials are needed to explore the primary and secondary prevention of STRE as well as to provide high-quality evidence on efficacy and tolerability of antiepileptic drugs to guide treatment of STRE. Robust pre-clinical and clinical prediction models of STRE are also needed to develop treatments to prevent the transformation of infarcted tissue into an epileptic focus.
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Affiliation(s)
- A M Feyissa
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - T F Hasan
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - J F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
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13
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Challenges in the Anesthetic and Intensive Care Management of Acute Ischemic Stroke. J Neurosurg Anesthesiol 2017; 28:214-32. [PMID: 26368664 DOI: 10.1097/ana.0000000000000225] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Acute ischemic stroke (AIS) is a devastating condition with high morbidity and mortality. In the past 2 decades, the treatment of AIS has been revolutionized by the introduction of several interventions supported by class I evidence-care on a stroke unit, intravenous tissue plasminogen activator within 4.5 hours of stroke onset, aspirin commenced within 48 hours of stroke onset, and decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction. There is new class I evidence also demonstrating benefits of endovascular therapy on functional outcomes in those with anterior circulation stroke. In addition, the importance of the careful management of key systemic physiological variables, including oxygenation, blood pressure, temperature, and serum glucose, has been appreciated. In line with this, the role of anesthesiologists and intensivists in managing AIS has increased. This review highlights the main challenges in the endovascular and intensive care management of AIS that, in part, result from the paucity of research focused on these areas. It also provides guidelines for the management of AIS based upon current evidence, and identifies areas for further research.
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14
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Holtkamp M, Beghi E, Benninger F, Kälviäinen R, Rocamora R, Christensen H. European Stroke Organisation guidelines for the management of post-stroke seizures and epilepsy. Eur Stroke J 2017; 2:103-115. [PMID: 31008306 DOI: 10.1177/2396987317705536] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 03/21/2017] [Indexed: 11/16/2022] Open
Abstract
Background Following stroke, acute symptomatic seizures (manifestation within seven days) and epilepsy, i.e. occurrence of at least one unprovoked seizure (manifestation after more than seven days), are reported in 3-6% and up to 12% of patients, respectively. Incidence of acute symptomatic seizures is higher in intracranial haemorrhage (10-16%) than in ischaemic stroke (2-4%). Acute symptomatic seizures and unprovoked seizure may be associated with unfavourable functional outcome and increased mortality. In view of the clinical relevance, the European Stroke Organisation has issued evidence-based guidelines on the management of post-stroke seizures and epilepsy. Method A writing committee of six clinicians and researchers from five European countries and Israel identified seven questions relating to prevention of (further) post-stroke seizures and epilepsy and to amelioration of functional outcome and prevention of mortality. Recommendations are based on findings in randomised controlled trials and observational studies using the grading of recommendations assessment, development and evaluation approach. Results In the absence of adequately powered randomised controlled trials, evidence for all recommendations is very low. Based on findings in observational studies, some weak recommendations have been made. In most instances, we suggest not to administer antiepileptic drugs. Due to high incidence of seizure recurrence after one post-stroke unprovoked seizure, secondary antiepileptic drugs prophylaxis needs to be considered. Conclusion Due to very low evidence, these guidelines only give some weak recommendations on prevention of occurrence and recurrence of post-stroke acute symptomatic seizures and unprovoked seizure. Adequately powered randomised controlled trials are required to assess interventions for post-stroke seizure management.
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Affiliation(s)
- Martin Holtkamp
- Epilepsy-Center Berlin-Brandenburg, Department of Neurology, Charité - Universitätsmedizin Berlin, Germany
| | - Ettore Beghi
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Dipartimento di Neuroscienze, Milano, Italy
| | - Felix Benninger
- Rabin Medical Center, Department of Neurology, Faculty of Medicine, Tel Aviv University, Beilinson Hospital, Tel Aviv, Israel
| | - Reetta Kälviäinen
- Kuopio Epilepsy Center/NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Rodrigo Rocamora
- Epilepsy Unit, Department of Neurology, Hospital Universitario del Mar, Barcelona, Spain
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
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15
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Delayed Seizures and Poor Functional Outcome after Intracranial Hemorrhage is the Fate of Patients with a Poor Underlying Substrate, Say the Intensivists. Epilepsy Curr 2017; 17:101-102. [DOI: 10.5698/1535-7511.17.2.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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16
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Tanaka T, Ihara M. Post-stroke epilepsy. Neurochem Int 2017; 107:219-228. [PMID: 28202284 DOI: 10.1016/j.neuint.2017.02.002] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 02/05/2017] [Accepted: 02/06/2017] [Indexed: 01/17/2023]
Abstract
Post-stroke epilepsy (PSE) is a common complication after stroke, yet treatment options remain limited. While many physicians prescribe antiepileptic drugs (AED) for secondary prevention of PSE, it is unclear which treatments are most effective in the prevention of recurrence of symptoms, or whether such therapy is needed for primary prevention. This review discusses the current understanding of epidemiology, diagnoses, mechanisms, risk factors, and treatments of PSE.
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Affiliation(s)
- Tomotaka Tanaka
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
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17
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Abstract
Stroke is among the most common causes of epilepsy after middle age. Patients with poststroke epilepsy (PSE) differ in several respects from patients with other forms of structural-metabolic epilepsy; not least in age, age-related sensitivity to side effects of antiepileptic drugs (AEDs), and specific drug-drug interaction issues related to secondary-stroke prophylaxis. Encouragingly, there has lately been remarkable activity in the study of PSE. Three developments in PSE research deserve particular focus. First, large prospective trials have established the incidence and risk factors of PSE in the setting of modern stroke care. Stroke severity, cortical location, young age, and haemorrhage remain the most important risk factors. Second, although more studies are needed, epidemiological data indicate that the risk of PSE may be influenced, for instance, by statin treatment. Third, studies are emerging regarding the treatment and prognosis of PSE. Levetiracetam and lamotrigine may be well tolerated treatment options and seizure freedom is achieved in at least a similar proportion of patients as in other epilepsies. Furthermore, new animal models such as photothrombotic stroke gives hope of a more clear understanding of PSE epileptogenesis in the near future. In summary, PSE shows indications of maturing into an independent epilepsy research field. This review summarizes recent advances in our understanding of PSE and provides an update on management issues such as diagnosis, AED selection, and prognosis. Finally, future research challenges in the field are outlined.
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Affiliation(s)
- Johan Zelano
- Department of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, SE41345 Gothenburg, Sweden
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18
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19
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The intensive care management of acute ischemic stroke: an overview. Intensive Care Med 2014; 40:640-53. [DOI: 10.1007/s00134-014-3266-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 03/11/2014] [Indexed: 01/21/2023]
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20
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Wijdicks EFM, Sheth KN, Carter BS, Greer DM, Kasner SE, Kimberly WT, Schwab S, Smith EE, Tamargo RJ, Wintermark M. Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:1222-38. [PMID: 24481970 DOI: 10.1161/01.str.0000441965.15164.d6] [Citation(s) in RCA: 306] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE There are uncertainties surrounding the optimal management of patients with brain swelling after an ischemic stroke. Guidelines are needed on how to manage this major complication, how to provide the best comprehensive neurological and medical care, and how to best inform families facing complex decisions on surgical intervention in deteriorating patients. This scientific statement addresses the early approach to the patient with a swollen ischemic stroke in a cerebral or cerebellar hemisphere. METHODS The writing group used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. The panel reviewed the most relevant articles on adults through computerized searches of the medical literature using MEDLINE, EMBASE, and Web of Science through March 2013. The evidence is organized within the context of the American Heart Association framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive American Heart Association internal peer review. RESULTS Clinical criteria are available for hemispheric (involving the entire middle cerebral artery territory or more) and cerebellar (involving the posterior inferior cerebellar artery or superior cerebellar artery) swelling caused by ischemic infarction. Clinical signs that signify deterioration in swollen supratentorial hemispheric ischemic stroke include new or further impairment of consciousness, cerebral ptosis, and changes in pupillary size. In swollen cerebellar infarction, a decrease in level of consciousness occurs as a result of brainstem compression and therefore may include early loss of corneal reflexes and the development of miosis. Standardized definitions should be established to facilitate multicenter and population-based studies of incidence, prevalence, risk factors, and outcomes. Identification of patients at high risk for brain swelling should include clinical and neuroimaging data. If a full resuscitative status is warranted in a patient with a large territorial stroke, admission to a unit with neurological monitoring capabilities is needed. These patients are best admitted to intensive care or stroke units attended by skilled and experienced physicians such as neurointensivists or vascular neurologists. Complex medical care includes airway management and mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control. In swollen supratentorial hemispheric ischemic stroke, routine intracranial pressure monitoring or cerebrospinal fluid diversion is not indicated, but decompressive craniectomy with dural expansion should be considered in patients who continue to deteriorate neurologically. There is uncertainty about the efficacy of decompressive craniectomy in patients ≥60 years of age. In swollen cerebellar stroke, suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically. Ventriculostomy to relieve obstructive hydrocephalus after a cerebellar infarct should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement. In swollen hemispheric supratentorial infarcts, outcome can be satisfactory, but one should anticipate that one third of patients will be severely disabled and fully dependent on care even after decompressive craniectomy. Surgery after a cerebellar infarct leads to acceptable functional outcome in most patients. CONCLUSIONS Swollen cerebral and cerebellar infarcts are critical conditions that warrant immediate, specialized neurointensive care and often neurosurgical intervention. Decompressive craniectomy is a necessary option in many patients. Selected patients may benefit greatly from such an approach, and although disabled, they may be functionally independent.
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21
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Sykes L, Wood E, Kwan J. Antiepileptic drugs for the primary and secondary prevention of seizures after stroke. Cochrane Database Syst Rev 2014:CD005398. [PMID: 24464793 DOI: 10.1002/14651858.cd005398.pub3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND This is an updated version of the original Cochrane review published in 2010, Issue 1. Seizures after stroke are an important clinical problem, and they may be associated with poor outcome. The effects of antiepileptic drugs for the primary and secondary prevention of seizures after stroke remain unclear. OBJECTIVES We aimed to assess the effects of antiepileptic drugs for the primary and secondary prevention of seizures after stroke. SEARCH METHODS We searched the Specialised Registers of the Cochrane Epilepsy Group (12 August 2013) and the Cochrane Stroke Group (12 August 2013), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2013, Issue 7), and MEDLINE (OVID, 1946 to 12 August 2013). We also checked the reference lists of articles retrieved from these searches. SELECTION CRITERIA Randomised and quasi-randomised controlled trials in which participants were assigned to treatment or control group (placebo or no drug). DATA COLLECTION AND ANALYSIS Two review authors independently screened all the titles, abstracts, and keywords of publications identified by the searches to assess their eligibility, and both review authors assessed their suitability for inclusion according to prespecified selection criteria. We included only one study for data collection and analysis. MAIN RESULTS We found only one trial that fulfilled the study inclusion criteria of comparison of the effects of an antiepileptic drug with placebo (or no drug) for the primary or secondary prevention of seizures after stroke. This was a prospective randomised, double-blind, placebo-controlled trial comparing valproic acid with placebo for primary prevention of seizures in 72 adults (over 18 years of age) with spontaneous non-aneurysmal, non-traumatic intracerebral haemorrhage; no statistically significant difference in outcome (seizure occurrence at one year) was demonstrated between groups. AUTHORS' CONCLUSIONS Currently, there is insufficient evidence to support the routine use of antiepileptic drugs for the primary or secondary prevention of seizures after stroke. Further well-conducted research is needed for this important clinical problem.
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Affiliation(s)
- Lucy Sykes
- Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital, Hampshire, UK
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22
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Hu X, Fang Y, Li H, Liu W, Lin S, Fu M, Li X, Cao X, Zhang H, You C, Liu M. Protocol for Seizure Prophylaxis following Intracerebral Hemorrhage Study (SPICH): A Randomized, Double-Blind, Placebo-Controlled Trial of Short-Term Sodium Valproate Prophylaxis in Patients with Acute Spontaneous Supratentorial Intracerebral Hemorrhage. Int J Stroke 2013; 9:814-7. [PMID: 24025111 DOI: 10.1111/ijs.12187] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Rationale Seizures after intracerebral hemorrhage are a common complication and may adversely affect neurological outcome. However, studies are inadequate on the utility of prophylactic anticonvulsant therapy in patients with hemorrhagic stroke, and the results remains controversial. Aims This study aims to determine if short-duration sodium valproate prevents seizure onset or improves the survival and neurological outcome in adults after acute spontaneous supratentorial intracerebral hemorrhage. Design In this randomized, double blinded, placebo-controlled trial, 258 patients meeting the inclusion criteria will be enrolled in the Department of Neurosurgery, West China Hospital. In addition to standard care, patients will be randomly assigned to receive seven-day prophylaxis of sodium valproate 500 mg daily (alternatively 400 mg daily by intravenous infusion in 250 ml 0·9% normal saline) or matching placebo. Patients will be followed up at seven-days, 3, 6, and 12 months. Study outcomes The primary outcomes are early (≤7 days) and late onset seizures (>7 days). Secondary outcomes include midline shift, enlargement of hematoma, death (all cause), adverse effects, and functional outcome assessed by Glasgow Outcome Scale and modified Rankin Scale. Discussion Given the lack of evidence for seizure prophylaxis in patients with acute supratentorial intracerebral hemorrhage, randomized controlled trials are desperately needed. The results from our study are believed to directly influence future prophylactic anticonvulsant therapy of intracerebral hemorrhage.
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Affiliation(s)
- X. Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Y. Fang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - H. Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - W. Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - S. Lin
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - M. Fu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - X. Li
- Department of Science and Technology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - X. Cao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - H. Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - C. You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - M. Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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Srejic LR, Valiante TA, Aarts MM, Hutchison WD. High-frequency cortical activity associated with postischemic epileptiform discharges in an in vivo rat focal stroke model. J Neurosurg 2013; 118:1098-106. [PMID: 23413946 DOI: 10.3171/2013.1.jns121059] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECT The postischemic brain has greater susceptibility to epileptogenic activity than physiologically healthy tissue. Epileptiform discharges are thought to exacerbate postischemic brain function. The aim of this study was to develop an in vivo focal stroke model in rats to characterize epileptiform activity. METHODS The authors developed a parasagittal 8-channel intracortical microelectrode array to obtain recordings of cortical oscillations of local field potentials following partial middle and anterior cerebral artery occlusion. All experiments were done in urethane-anesthetized Sprague-Dawley rats. RESULTS Theta runs (TRs), ranging in duration from 5 seconds to 5 minutes, were observed in 62% of animals within 1 hour of occlusion. High-frequency oscillations (HFOs) in the high gamma range (80-120 Hz) were observed 5-15 seconds before each TR and terminated at the onset of the discharge. Periodic epileptiform discharges (PEDs) were detected in 54% of rats following ischemia. The PEDs consisted of an early negative slow wave, a high-amplitude positive spike, and a short negative slow wave. Transient HFOs in the low gamma range (30-70 Hz) occurred during the first negative wave and the rising phase of the positive spike of the PED. CONCLUSIONS These recordings provide the first intracortical evidence of a high-frequency component that could be an important element for diagnosis and intervention in postischemic epileptogenic activity. The early onset also suggests that HFOs could serve as a reliable method of detecting small epileptiform events and could be used as a consideration in deciding whether antiepileptic medications are appropriate as part of a patient's poststroke care.
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Affiliation(s)
- Luka R Srejic
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
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24
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Abstract
Seizures and stroke are both common neurologic conditions, but when they occur in close temporal proximity they produce much more concern than either does alone. The stroke specialist (and the family) fear that convulsions will worsen the stroke because of acute hypertension and airway compromise, and the epileptologist is concerned that these acute seizures are the harbingers of later epilepsy. Other less commonly recognized but important aspects of this relationship are that subclinical seizures worsen some forms of stroke, and some anticonvulsants may have more adverse effects on stroke patients than they do in other groups. In surveying the connections between these two conditions, I have attempted to address seven questions. For some questions, there are data to help provide an answer; for others, there is only opinion; and for a maddening few, newer research is making older suggestions less certain.
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Affiliation(s)
- Thomas P. Bleck
- Professor of Neurological Sciences, Neurosurgery, Internal Medicine, and Anesthesiology, Rush Medical College, Chicago, IL
- Associate Chief Medical Officer (Critical Care), Rush University Medical Center, Chicago, IL
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25
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Abstract
PURPOSE OF REVIEW Acute ischemic stroke (AIS) can have profound and devastating effects on the CNS and several other organs. Approximately 15% to 20% of patients with AIS are admitted to an intensive care unit and cared for by a multidisciplinary team. This article discusses the critical care management of patients with AIS. RECENT FINDINGS Patients with AIS require attention to airway, pulmonary status, blood pressure, glucose, temperature, cardiac function, and, sometimes, life-threatening cerebral edema. SUMMARY The lack of disease-specific data has led to numerous management approaches and limited guidance on choosing among them. Existing guidelines emphasize risk factors, prevention, natural history, and prevention of bleeding but provide little discussion of the complex critical care issues involved in caring for patients with AIS.
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Affiliation(s)
- William M Coplin
- Wayne State University, Department of Neurology, 4201 St. Antoine-8C, Detroit, MI 48201, USA.
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26
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Belcastro V. Neuroprotection in post-stroke epilepsy: A realistic goal? Seizure 2011; 20:665. [DOI: 10.1016/j.seizure.2011.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Accepted: 04/22/2011] [Indexed: 10/18/2022] Open
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