Poststroke Epilepsy

Nrf2 and Ferroptosis: Exploring Translational Avenues for Therapeutic Approaches to Neurological Diseases

Nrf2, a crucial protein involved in defense mechanisms, particularly oxidative stress, plays a significant role in neurological diseases (NDs) by reducing oxidative stress and inflammation. NDs, including Alzheimer's, Parkinson's, Huntington's, amyotrophic lateral sclerosis, stroke, epilepsy, schizophrenia, depression, and autism, exhibit ferroptosis, iron-dependent regulated cell death resulting from lipid and iron-dependent reactive oxygen species (ROS) accumulation. Nrf2 has been shown to play a critical role in regulating ferroptosis in NDs. Age-related decline in Nrf2 expression and its target genes (HO-1, Nqo-1, and Trx) coincides with increased iron-mediated cell death, leading to ND onset. The modulation of iron-dependent cell death and ferroptosis by Nrf2 through various cellular and molecular mechanisms offers a potential therapeutic pathway for understanding the pathological processes underlying these NDs. This review emphasizes the mechanistic role of Nrf2 and ferroptosis in multiple NDs, providing valuable insights for future research and therapeutic approaches.

Comorbidities, long-term outcome and poststroke epilepsy associated with ischemic stroke - A multicenter observational study of 125 dogs

BACKGROUND

Little is known regarding the comorbidities and prognostic factors associated with the long-term outcome of ischemic stroke in dogs. Although poststroke epilepsy is a well-recognized syndrome in people, it is unclear if this phenomenon also occurs in dogs.

HYPOTHESIS/OBJECTIVE

Document comorbidities, long-term outcome (survival and stroke recurrence), and occurrence of epileptic seizures associated with ischemic stroke.

ANIMALS

One hundred and twenty-five client-owned dogs.

METHODS

Multicenter observational study including dogs diagnosed with ischemic stroke between 2000 and 2021. Associations between comorbidities, stroke location and extent, poststroke epileptic seizures, and long-term outcome were investigated. Referring veterinarians and owners were contacted to obtain follow-up information.

RESULTS

Fifty-two dogs (41.6%) had a comorbidity. The most common comorbidities were hypertension (20%) and proteinuria (8%). Eight dogs (6.4%) that did not survive to discharge had a territorial ischemic stroke. Overall median survival time for dogs with a comorbidity was 482 days (range, 1-3013) and 907 days (range, 1-3027) in dogs without comorbidities (Kaplan-Meier survival analysis P = .602). Twenty-four dogs (19.2%) had a suspected stroke recurrence and a total of 8/109 dogs (7.3%) developed poststroke epilepsy. No association was found between suspected stroke recurrence or development of poststroke epilepsy and survival (P = .812, P = .487).

CONCLUSIONS AND CLINICAL IMPORTANCE

Despite no significant difference in survival of dogs diagnosed with ischemic stroke, with or without comorbidities, investigations for underlying causes are recommended to provide appropriate treatment. Poststroke epilepsy is uncommon.

Causal associations of ischemic stroke, metabolic factors, and related medications with epilepsy: a Mendelian randomization study

Background

Earlier researches have demonstrated that ischemic stroke, metabolic factors, and associated medications may influence the risk of epilepsy. Nevertheless, the causality between these elements and epilepsy remains inconclusive. This study aims to examine whether ischemic stroke, metabolic factors, and related medications affect the overall risk of epilepsy.

Methods

We used single nucleotide polymorphisms associated with ischemic stroke, hypothyroidism, hypertension, blood glucose levels, high cholesterol, serum 25-Hydroxyvitamin D levels, testosterone, HMG CoA reductase inhibitors, and beta-blocking agents as instrumental variables in a Mendelian randomization technique to investigate causality with epilepsy. Multiple sensitivity methods were performed to evaluate pleiotropy and heterogeneity.

Results

The IVW analysis revealed positive associations between ischemic stroke (OR = 1.29; p = 0.020), hypothyroidism (OR = 1.05; p = 0.048), high blood pressure (OR = 1.10; p = 0.028), high cholesterol (OR = 1.10; p = 0.024), HMG CoA reductase inhibitors (OR = 1.19; p = 0.003), beta-blocking agents (OR = 1.20; p = 0.006), and the risk of epilepsy. Conversely, blood glucose levels (OR = 0.79; p = 0.009), serum 25-Hydroxyvitamin D levels (OR = 0.75; p = 0.020), and testosterone (OR = 0.62; p = 0.019) exhibited negative associations with the risk of epilepsy. Sensitivity analyses confirmed the robustness of these findings (p > 0.05).

Conclusion

Our research suggests that ischemic stroke, hypothyroidism, high blood pressure, high cholesterol, HMG CoA reductase inhibitors, and beta-blockers may increase the risk of epilepsy, whereas serum 25-Hydroxyvitamin D levels and blood glucose levels may reduce the risk.

Angiotensin Receptor Blockers for Hypertension and Risk of Epilepsy

Importance

Animal and human studies have suggested that the use of angiotensin receptor blockers (ARBs) may be associated with a lower risk of incident epilepsy compared with other antihypertensive medications. However, observational data from the US are lacking.

Objective

To evaluate the association between ARB use and epilepsy incidence in subgroups of US patients with hypertension.

Design, Setting, and Participants

This retrospective cohort study used data from a national health administrative database from January 2010 to December 2017 with propensity score (PS) matching. The eligible cohort included privately insured individuals aged 18 years or older with diagnosis of primary hypertension and dispensed at least 1 ARB, angiotensin-converting enzyme inhibitor (ACEI), β-blocker, or calcium channel blocker (CCB) from 2010 to 2017. Patients with a diagnosis of epilepsy at or before the index date or dispensed an antiseizure medication 12 months before or 90 days after initiating the study medications were excluded. The data analysis for this project was conducted from April 2022 to April 2024.

Exposures

Propensity scores were generated based on baseline covariates and used to match patients who received ARBs with those who received either ACEIs, β-blockers, CCBs, or a combination of these antihypertensive medications.

Main Outcomes and Measures

Cox regression analyses were used to evaluate epilepsy incidence during follow-up comparing the ARB cohort with other antihypertensive classes. Subgroup and sensitivity analyses were conducted to examine the association between ARB use and epilepsy incidence in various subgroups.

Results

Of 2 261 964 patients (mean [SD] age, 61.7 [13.9] years; 1 120 630 [49.5%] female) included, 309 978 received ARBs, 807 510 received ACEIs, 695 887 received β-blockers, and 448 589 received CCBs. Demographic and clinical characteristics differed across the 4 comparison groups prior to PS matching. Compared with ARB users, patients receiving ACEIs were predominantly male and had diabetes, CCB users were generally older (eg, >65 years), and β-blocker users had more comorbidities and concurrent medications. The 1:1 PS-matched subgroups included 619 858 patients for ARB vs ACEI, 619 828 patients for ARB vs β-blocker, and 601 002 patients for ARB vs CCB. Baseline characteristics were equally distributed between comparison groups after matching with propensity scores. Use of ARBs was associated with a decreased incidence of epilepsy compared with ACEIs (adjusted hazard ratio [aHR], 0.75; 95% CI, 0.58-0.96), β-blockers (aHR, 0.70; 95% CI, 0.54-0.90), and a combination of other antihypertensive classes (aHR, 0.72; 95% CI, 0.56-0.95). Subgroup analyses revealed a significant association between ARB use (primarily losartan) and epilepsy incidence in patients with no preexisting history of stroke or cardiovascular disease.

Conclusions and Relevance

This cohort study found that ARBs, mainly losartan, were associated with a lower incidence of epilepsy compared with other antihypertensive agents in hypertensive patients with no preexisting stroke or cardiovascular disease. Further studies, such as randomized clinical trials, are warranted to confirm the comparative antiepileptogenic properties of antihypertensive medications.

Risk Factors and Temporal Patterns of Poststroke Epilepsy across Stroke Subtypes: Insights from a Nationwide Cohort Study in Korea

INTRODUCTION

We aimed to investigate the risk factors associated with poststroke epilepsy (PSE) among patients with different subtypes of stroke, focusing on age-related risk and time-varying effects of stroke subtypes on PSE development.

METHODS

A retrospective, nationwide, population-based cohort study was conducted using Korean National Health Insurance Service-National Sample Cohort data. Patients hospitalized with newly diagnosed stroke from 2005 to 2015 were included and followed up for up to 10 years. The primary outcome was the development of PSE, defined as having a diagnostic code and a prescription for anti-seizure medication. Multivariable Cox proportional hazard models were used to estimate PSE hazard ratios (HRs), and time-varying effects were also assessed.

RESULTS

A total of 8,305 patients with ischemic stroke, 1,563 with intracerebral hemorrhage (ICH), and 931 with subarachnoid hemorrhage (SAH) were included. During 10 years of follow-up, 4.6% of patients developed PSE. Among patients with ischemic stroke, significant risk factors for PSE were younger age (HR = 1.47), living in rural areas (HR = 1.35), admission through the emergency room (HR = 1.33), and longer duration of hospital stay (HR = 1.45). Time-varying analysis revealed elevated HRs for ICH and SAH, particularly in the first 2 years following the stroke. The age-specific HRs also showed an increased risk for those under the age of 65, with a noticeable decrease in risk beyond that age.

CONCLUSION

The risk of developing PSE varies according to stroke subtype, age, and other demographic factors. These findings underscore the importance of tailored poststroke monitoring and management strategies to mitigate the risk of PSE.

Clinical characteristics and outcomes of patients with post-stroke epilepsy: protocol for an individual patient data meta-analysis from the International Post-stroke Epilepsy Research Repository (IPSERR)

INTRODUCTION

Despite significant advances in managing acute stroke and reducing stroke mortality, preventing complications like post-stroke epilepsy (PSE) has seen limited progress. PSE research has been scattered worldwide with varying methodologies and data reporting. To address this, we established the International Post-stroke Epilepsy Research Consortium (IPSERC) to integrate global PSE research efforts. This protocol outlines an individual patient data meta-analysis (IPD-MA) to determine outcomes in patients with post-stroke seizures (PSS) and develop/validate PSE prediction models, comparing them with existing models. This protocol informs about creating the International Post-stroke Epilepsy Research Repository (IPSERR) to support future collaborative research.

METHODS AND ANALYSIS

We utilised a comprehensive search strategy and searched MEDLINE, Embase, PsycInfo, Cochrane, and Web of Science databases until 30 January 2023. We extracted observational studies of stroke patients aged ≥18 years, presenting early or late PSS with data on patient outcome measures, and conducted the risk of bias assessment. We did not apply any restriction based on the date or language of publication. We will invite these study authors and the IPSERC collaborators to contribute IPD to IPSERR. We will review the IPD lodged within IPSERR to identify patients who developed epileptic seizures and those who did not. We will merge the IPD files of individual data and standardise the variables where possible for consistency. We will conduct an IPD-MA to estimate the prognostic value of clinical characteristics in predicting PSE.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study. The results will be published in peer-reviewed journals. This study will contribute to IPSERR, which will be available to researchers for future PSE research projects. It will also serve as a platform to anchor future clinical trials.

TRIAL REGISTRATION NUMBER

NCT06108102.

Application of physiologically-based pharmacokinetic model approach to predict pharmacokinetics and drug-drug interaction of rivaroxaban: A case study of rivaroxaban and carbamazepine

Rivaroxaban (RIV; Xarelto; Janssen Pharmaceuticals, Beerse, Belgium) is one of the direct oral anticoagulants. The drug is a strong substrate of cytochrome P450 (CYP) enzymes and efflux transporters. This study aimed to develop a physiologically-based pharmacokinetic (PBPK) model for RIV. It contained three hepatic metabolizing enzyme reactions (CYP3A4, CYP2J2, and CYP-independent) and two active transporter-mediated transfers (P-gp and BCRP transporters). To illustrate the performance of the developed RIV PBPK model on the prediction of drug-drug interactions (DDIs), carbamazepine (CBZ) was selected as a case study due to the high DDI potential. Our study results showed that CBZ significantly reduces the exposure of RIV. The area under the concentration-time curve from zero to infinity (AUC_inf ) of RIV was reduced by 35.2% (from 2221.3 to 1438.7 ng*h/ml) and by 25.5% (from 2467.3 to 1838.4 ng*h/ml) after the first dose and at the steady-state, respectively, whereas the maximum plasma concentration (C_max ) of RIV was reduced by 37.7% (from 266.3 to 166.1 ng/ml) and 36.4% (from 282.3 to 179.5 ng/ml), respectively. The developed PBPK model of RIV could be paired with PBPK models of other interested perpetrators to predict DDI profiles. Further studies investigating the extent of DDI between CBZ and RIV should be conducted in humans to gain a full understanding of their safety and effects.

Burden of acute symptomatic seizures in cerebral venous sinus thrombosis: A nationwide United States analysis

INTRODUCTION

Acute symptomatic seizures (ASS) are seen in one-third of cerebral venous sinus thrombosis (CVT) cases either as the presenting symptom or shortly after diagnosis in the acute phase. The goal of our study was to assess the trends in recognition of ASS in CVT over the years and to determine factors predictive of ASS in the patients with CVT for early identification of candidates who would benefit from anti-seizure medications (ASM).

MATERIALS AND METHODS

The Nationwide Inpatient Sample (NIS) database was accessed to identify adult inpatient admissions with a primary or secondary diagnosis of CVT. Comorbidities, complications, risk factors, and procedures pertaining to these hospitalizations were compared between CVT patients with and without ASS.

RESULTS

A total of 53,710 CVT-related hospitalizations were identified, of which 18.1% of patients had a burden of ASS at presentation or subsequently during hospitalization. CVT patients with ASS had a longer average duration of hospitalization and higher overall morbidity and mortality.

CONCLUSIONS

Our study showed ~one in five patients (18.1%) with CVT had ASS. ASS patients had higher odds of mortality and disability at discharge, requiring post-discharge rehabilitation care. It is crucial to identify risk factors of ASS in the CVT population to avoid future preventable revisit related to seizures. Additional research is required for risk stratification of patients with CVT for primary and secondary seizure prophylaxis and determining the appropriate choice and duration of ASM in these patients.

Raised high-sensitivity C-reactive protein and cognitive impairment among African stroke survivors within the first three months following stroke

Stroke remains a major factor causing death and disabilities such as cognitive impairment. There is conflicting evidence on the role and dynamics of high sensitivity C-reactive protein (hsCRP), an acute phase pro-inflammatory protein, in post-stroke cognitive impairment. This study evaluated cognitive impairment and examined its relationship with serum hsCRP in the first three months following stroke. Cognition was assessed using Montreal Cognitive Assessment test, while serum hsCRP concentrations were assessed using enzyme link immunosorbent assay kit. Data were processed using SPSS Statistics version 20.0. Sixty subjects, comprising of 30 stroke patients and 30 healthy subjects, matched for age, sex and level of education were studied. Cognitive impairment was observed among the stroke patients, while the healthy subjects showed normal cognitive function; and the difference in the cognitive scores of the two groups was highly significant (P = 0.001). There was higher prevalence of cognitive impairment among the stroke survivors compared to the non-stroke subjects. Serum hsCRP was significantly higher among the stroke survivors compared to the healthy subjects (P = 0.001). The high hsCRP level correlates well with duration of stroke and working memory domain of cognition. The data revealed a high prevalence of cognitive impairment and concurrent high serum hsCRP levels among stroke survivors in the first three months following stroke, in contrast with normal subjects. The high hsCRP level correlates with duration of stroke and working memory domain of cognition. The data suggest a role for serum hsCRP and inflammation in the development of post-stroke cognitive impairment.

Effects of Carbamazepine and Phenytoin on Pharmacokinetics and Pharmacodynamics of Rivaroxaban

Rivaroxaban (RIV) is commonly prescribed with carbamazepine or phenytoin (CBZ/PHT) in post-stroke seizure or post-stroke epilepsy patients. Although adverse events have been reported in several previous studies when they are coadministered, there are no studies of the interactions between these drugs. Therefore, our study was conducted to solve this lack of information. The potential effects of CBZ/PHT were investigated by comparing the pharmacokinetic (PK) and pharmacodynamic (PD) parameters of RIV between the control group (RIV alone) and the test groups (RIV administered with CBZ/PHT) in rats using the noncompartmental analysis (NCA) and the compartmental model approach. The NCA results indicate that AUC_t of RIV decreased by 57.9% or 89.7% and C_max of RIV decreased by 43.3% or 70.0% after administration of CBZ/PHT, respectively. In addition, both CBZ and PHT generally reduced the effects of RIV on the prothrombin times of the blood samples. PK profiles of RIV were most properly described by a two-compartment disposition model with a mixed first- and zero-order absorption kinetics and a first-order elimination kinetics. The compartmental model approach showed that a 211% or 1030% increase in CL/F of RIV and a 33.9% or 43.4% increase in D2 of RIV were observed in the test groups by the effects of CBZ/PHT, respectively. In conclusion, CBZ and PHT significantly reduced RIV exposure and therefore reduced the therapeutic effects of RIV. Consequently, this might result in adverse events due to insufficient RIV concentration to attain its therapeutic effects. Further studies are needed to validate this finding.

The influence of statins on the risk of post-stroke epilepsy

BACKGROUND

Currently, statins are widely used for secondary prevention of stroke due to their pleiotropic neuroprotective effects. Epilepsy is a common complication of cerebrovascular diseases. The purpose of this study was to evaluate the effect of statin therapy on the occurrence of post-stroke epilepsy (PSE).

METHODS

In this prospective cohort study, patients who suffered an ischemic stroke and without history of epilepsy before stroke were enrolled. At baseline, patients were classified according to the particularities of statin therapy. Statin use onset and adherence to treatment were registered as well. After a follow-up period of 1 year, we assessed the occurrence of seizures and PSE.

RESULTS

Among the 477 patients included in our cohort, there were 91 (19.1%) patients without statins, 160 (33.5%) with simvastatin 20 mg, 180 (37.7%) with simvastatin 40 mg, and 46 (9.6%) with high-potency statins. Overall, PSE emerged in 53 (11.1%) patients. PSE was significantly more prevalent among those who did not receive statins and those with lower doses of simvastatin. Acute onset of statin use was associated with reduced odds of having PSE.

CONCLUSION

Adequate treatment with statins after stroke may lower the risk of PSE.

Seizures Do Not Affect Disability and Mortality Outcomes of Stroke: A Population-Based Study

Although seizures are frequently seen after cerebrovascular accidents, their effects on long-term outcome in stroke patients are still unknown. Therefore, the aim of this study was to investigate the relationship between post-stroke seizures and the risk of long-term disability and mortality in stroke patients. This study is part of a larger population-based study. All patients were prospectively followed up by a face-to-face interview or a structured telephone interview. We enrolled 635 patients with first-ever stroke and without a history of seizures. Prevalence of ischemic stroke (IS) was 85.2%, while the remaining 14.8% of patients were affected by intracerebral hemorrhage (ICH). During the study period, 51 subjects (8%) developed post-stroke seizures. Patients with post-stroke seizures were younger, had a higher prevalence of ICH, had a more severe stroke at admission, were more likely to have an IS involving the total anterior circulation, and were more likely to have a lobar ICH than patients without seizures. Moreover, subjects with seizures had more frequently hemorrhagic transformation after IS and cortical strokes. At 24 months, the risk of disability in patients with seizures was almost twice than in those without seizures. However, the negative effect of seizures disappeared in multivariate analysis. Kaplan-Meier survival curves at 12 years were not significantly different between patients with and without post-stroke seizures. Using the Cox multivariate analysis, age, NIHSS at admission, and pre-stroke mRS were independently associated with all-cause long-term mortality. In our sample, seizures did not impair long-term outcome in patients affected by cerebrovascular accidents. The not significant, slight difference in favor of a better survival for patients with seizures may be attributed to the slight age difference between the two groups.

Epilepsy in the Elderly: Treatment and Consideration of Comorbid Diseases

Epilepsy is the third most common neurological disorder affecting older adults after stroke and dementia, and the incidence of epilepsy is increasing rapidly in this population. A further increase in the incidence and prevalence of epilepsy is expected in aging societies. The establishment of a correct differential diagnosis between epilepsy and other seizure disorders that are common in the elderly is crucial. The symptoms of seizures in the elderly may be different from those in younger populations. The diagnosis is difficult, probably because of nonspecific characteristics, short-term symptoms, and absence of witnesses. There are three important issues in the treatment of epilepsy in the elderly: changes in pharmacokinetic parameters, polytherapy (including non-antiepileptic and antiepileptic drugs), and susceptibility to adverse drug effects. Antiepileptic drugs (AEDs) with fewer adverse effects, including cognitive effects, and AEDs without significant pharmacokinetic drug interactions are needed. Several studies found that stroke was strongly associated with a high incidence of early seizures and epilepsy. Stroke is also one of the major causes of status epilepticus. Cortical involvement and large lesions are strongly associated with the development of seizures and epilepsy. The severity of the initial neurological deficit is a strong clinical predictor of seizures after ischemic stroke. The optimal quality of life of dementia patients cannot be achieved without a proper diagnosis of coexisting epilepsy.

[Epileptic seizures and epilepsy after a stroke : Incidence, prevention and treatment]

Following stroke, 3-6% of patients develop acute symptomatic seizures within the first 7 days. The rate is higher after cerebral haemorrhage compared to ischaemia. In 10-12% of patients, after more than 7 days unprovoked seizures occur. Due to these low incidence rates, primary prophylaxis with antiepileptic drugs is generally not necessary. Following one acute symptomatic seizure, recurrence risk within the first 7 days post-stroke is 10-20%, generally arguing against secondary prophylaxis with an antiepileptic drug. In clinical practice however, antiepileptic drug treatment in this constellation is often initiated. If this is done, the antiepileptic drug should be withdrawn soon after the acute phase, as the long-term risk for manifestation of an unprovoked seizure is approximately 30%. Following one post-stroke unprovoked seizure, recurrence risk within the next 10 years is more than 70%, this defines epilepsy. In this case, antiepileptic drug treatment is regularly recommended.

Seizure in cerebral venous and sinus thrombosis

Many conflicting issues exist about seizure in the setting of cerebral venous and sinus thrombosis (CVST). In this article we aimed to address the existing data regarding incidence, characteristics, predictors, treatment, and prognosis of acute and late seizures in patients with CVST and to prepare more practical information for clinicians. PubMed, Embase, Web of science and Cochrane databases were searched within 1966–2016 using relevant keywords. A total of 63 papers met the inclusion criteria. Seizures are classified as acute symptomatic seizures (ASS; first 14 days) and post‐CVST epilepsy (PCE; after 14 days). The incidence had been reported in a wide range of 6.9–76% for ASS and 4–16% for PCE. Focal and generalized seizures were observed with different predominance. ASS commonly occurred in patients with loss of consciousness, focal neurological deficits, supratentorial lesions and thrombosis in superior sagittal sinus, straight sinus, and cortical veins. PCE had been predisposed by occurrence of ASS, motor deficit, and supratentorial lesions, particularly hemorrhage. Most experts believe that primary prophylaxis with antiepileptic drugs in the acute phase is not indicated. However, the initiation of prophylaxis after the first seizure in patients with supratentorial lesions or focal neurological deficit should be recommended. The quality of current evidence is low and most conclusions are based on expert opinions. More accurate reports of seizure semiology, detailed antiepileptic treatment plans, and outcomes are necessary to answer the existing questions.

The occurrence of seizures after ischemic stroke does not influence long-term mortality; a 26-year follow-up study

Objective

Epileptic seizures are a common complication after stroke. The relation between occurrence of seizures after stroke and long-term mortality remains elusive. We aimed to assess whether seizures in an early or late phase after ischemic stroke are an independent determinant of long-term mortality.

Methods

We prospectively included and followed 444 ischemic stroke patients with a first-ever supratentorial brain infarct for at least 2 years after their stroke regarding the occurrence of seizures. The final follow-up for mortality is from April 2015 (follow-up duration 24.5–27.8 years, mean 26.0 years, SD 0.9 years). We compared patients with early-onset seizures with all seizure-free patients, whereas the patients with late-onset seizures were compared with the 1-week survivors without any seizures. We used Cox-regression analyses to correct for possible confounding factors.

Results

Kaplan–Meier analysis showed significantly higher mortality for the patients with early-onset seizures (p = 0.002) but after correction for known risk factors for (long term) mortality early-onset seizures had no independent influence on long-term mortality (HR 1.09; 95% CI 0.64–1.85). In patients with late-onset seizures, no significant influence from late-onset seizures on long-term mortality was found (univariate p = 0.717; multivariate HR 0.81; 95% CI 0.54–1.20).

Conclusion

Both early-onset and late-onset seizures do not influence long-term mortality after ischemic stroke.

Mortality after primary intracerebral hemorrhage in relation to post-stroke seizures

Seizures after intracerebral hemorrhage are repeatedly seen. Whether the development of seizures after intracerebral hemorrhage affects survival in the long term is unknown. This study aims to determine the relation between seizures (i.e., with and without anti-epileptic therapy) and long-term mortality risk in a large patient population with intracerebral hemorrhage. We retrospectively included patients with a non-traumatic ICH in all three hospitals in the South Limburg region in the Netherlands between January 1st 2004 and December 31st 2009, and we assessed all-cause mortality until March 14th 2016. Patient who did not survive the first seven days after intracerebral hemorrhage were excluded from analyses. We used Cox multivariate analyses to determine independent predictors of mortality. Of 1214 patients, 783 hemorrhagic stroke patients fulfilled the inclusion criteria, amongst whom 37 (4.7%) patients developed early seizures (within 7 days after hemorrhage) and 77 (9.8%) developed late seizures (more than 7 days after hemorrhage). Seizure development was not significantly related to mortality risk after correction for conventional vascular risk factors and hemorrhage severity. However, we found a small but independent relation between the use of anti-epileptic drugs and a lower long-term mortality (HR = 0.32, 95% CI 0.11–0.91). In our large population, seizures and epilepsy did not relate independently to an increased mortality risk after hemorrhage.

Animal Models of Posttraumatic Seizures and Epilepsy

Posttraumatic epilepsy (PTE) is one of the most common and devastating complications of traumatic brain injury (TBI). Currently, the etiopathology and mechanisms of PTE are poorly understood and as a result, there is no effective treatment or means to prevent it. Antiepileptic drugs remain common preventive strategies in the management of TBI to control acute posttraumatic seizures and to prevent the development of PTE, although their efficacy in the latter case is disputed. Different strategies of PTE prophylaxis have been showing promise in preclinical models, but their translation to the clinic still remains elusive due in part to the variability of these models and the fact they do not recapitulate all complex pathologies associated with human TBI. TBI is a multifaceted disorder reflected in several potentially epileptogenic alterations in the brain, including mechanical neuronal and vascular damage, parenchymal and subarachnoid hemorrhage, subsequent toxicity caused by iron-rich hemoglobin breakdown products, and energy disruption resulting in secondary injuries, including excitotoxicity, gliosis, and neuroinflammation, often coexisting to a different degree. Several in vivo models have been developed to reproduce the acute TBI cascade of events, to reflect its anatomical pathologies, and to replicate neurological deficits. Although acute and chronic recurrent posttraumatic seizures are well-recognized phenomena in these models, there is only a limited number of studies focused on PTE. The most used mechanical TBI models with documented electroencephalographic and behavioral seizures with remote epileptogenesis include fluid percussion, controlled cortical impact, and weight-drop. This chapter describes the most popular models of PTE-induced TBI models, focusing on the controlled cortical impact and the fluid percussion injury models, the methods of behavioral and electroencephalogram seizure assessments, and other approaches to detect epileptogenic properties, and discusses their potential application for translational research.

Profile of epilepsy in a regional hospital in Al qassim, saudi arabia

INTRODUCTION

Epilepsy is a diverse set of chronic neurological disorders characterized by seizures. It is one of the most common of the serious neurological disorders. About 3% of people will be diagnosed with epilepsy at some time in their lives.

OBJECTIVES

We aimed to address the commonest types of seizures, their aetiologies, EEG and neuroimaging results and prognosis of patients presented to neurology services of the King Fahad Specialist Hospital- AlQassim (KFSH).

METHODOLOGY

In this retrospective epidemiological study we investigated the medical records of patients with epilepsy, who attended the neurology services of KFSH, during the study period (26/10/2011-26/4/2012).

RESULTS

The study included 341 patients; 189 (55.4%) males and 152 (44.6%) females. Their ages ranged between 12 and 85 years (mean ± SD = 31±16.9). The majority of patients had Generalised Tonic Clonic Seizures (76.2%), followed by Complex Partial Seizures (7.6%). 73% of our patients had idiopathic epilepsy. The commonest causes for symptomatic epilepsy were Cerebro Vascular Accidents and Head trauma. Hemiplegia, mental retardation and psychiatric illness were the commonest comorbidity. 69.3% of patients had controlled seizures. Patients with idiopathic epilepsy were significantly controlled than patients with symptomatic epilepsy (P=0.01), and those using one Anti Epileptic Drug were significantly controlled compared to patients using polytherapy (P=0.0001) there was no significant relation between controlled seizure and duration of illness or hospitalization or EEG changes.

CONCLUSION

Seizure types, aetiology, drug therapy, Comorbidities and outcome in a tertiary care hospital in Saudi Arabia are similar to previous local and international studies. 35.3% of patients were hospitalized, higher rates than previous studies. Seizure control was better in generalized seizures and idiopathic epilepsy compared to complex partial seizures or partial seizures with secondary generalization and symptomatic epilepsy.

Analysis of risk factors for first seizure after stroke in Chinese patients

The aim of this study is to assess related risk factors and predict early- and late-onset seizure after first-ever stroke. A total of 2474 consecutive patients with initial stroke in China from 1997 to 2007 were retrospectively investigated, in which, 24 clinical and radiological indexes were used for evaluation. Odds ratio (OR) and 95% confidence interval (CI) were calculated by logistic regression. A total of 232 (11.1%) of patients developed seizures during a mean follow-up period of 18 months, with 123 experiencing early-onset and 109 late-onset seizure. The independent risk factors for early-onset seizure were large lesion (OR = 9.36), subarachnoid hemorrhage (OR = 5.28), initial hyponatremia (OR = 2.10), and cortical involvement (OR = 1.33). The independent risk factors for late-onset seizure were cortical involvement (OR = 11.84) and large lesion (OR = 1.87). These results demonstrated that the risk factors for early seizure after stroke are large lesion, subarachnoid hemorrhage, and cortical involvement. Surprisingly, hyponatremia also predicts seizure in stroke patients. Cortical involvement is a major risk factor for late-onset seizure after stroke.

Prognostic value of early epileptic seizures on mortality and functional disability in acute stroke: the Dijon Stroke Registry (1985-2010)

We aimed to evaluate the prognostic value of early epileptic seizures after stroke. All consecutive patients with a first-ever stroke were prospectively identified within the population of Dijon, France, thanks to a population-based registry, from 1985 to 2010. Early epileptic seizures were defined as seizures occurring within 14 days after stroke onset. Outcomes were 1-month and 1-year mortality, and severe functional handicap at discharge. Of the 4,411 stroke patients included, data about seizures were available in 4,358 (98.8, 53.5 % women, mean age, 74.1 ± 14.8 years). Among these patients, 134 (3.1 %) had early seizures. Stroke patients with early seizures differed from those without seizures, as there was a higher proportion of hemorrhagic stroke, higher blood glucose level at admission, smoking status, and more frequent impaired. Higher risks of 1-month and 1-year mortality in patients with early seizures (unadjusted HR 1.45, 95 % CI 1.00-2.10; HR = 1.59, 95 % CI 1.21-2.09, respectively) disappeared (HR 0.71, 95 % CI 0.49-1.08 and HR 0.85, 95 % CI 0.64-1.17) after adjustment for stroke severity and other confounding factors. Early seizures were associated with severe handicap in unadjusted analyses (OR 2.07, 95 % CI 1.46-2.95) but the association was no longer significant after multivariable adjustment (OR 1.12, 95 % CI 0.69-1.83). Early epileptic seizures were not associated with higher risks of mortality at 1 month and 1 year or with unfavorable functional outcome after acute stroke. The adverse effects of epileptic seizures may not be distinguishable from stroke severity, which is strongly related to epileptic seizures.

Status epilepticus as the initial presentation of intravascular lymphoma

Intravascular lymphoma (IVL) is a rare disease form of malignant lymphoma, and it is characterised by the selective growth of lymphoma cells within the lumina of vessels. Identification of this disease at an early stage is difficult because of non-specific clinical symptoms and neuroradiological findings. Most reported IVL cases are diagnosed at post-mortem following autopsy. We report the case of a patient who presented with status epilepticus (SE) as the initial manifestation of IVL. Despite the administration of anti-convulsant agents and general care the patient's condition deteriorated rapidly after admission, culminating in death due to respiratory failure and heart failure 21 days after the onset of symptoms. Post-mortem examination revealed IVL in the brain and multiple organs. Epileptic seizures often appear during the clinical course of IVL; however, they occur most frequently at advanced stages. Diagnosis of IVL that first presents with SE is of clinical importance because the treatment and prognosis of acute SE arising from IVL are different from those of SE originating from other causes.

The incidence rate of post-stroke epilepsy: a 5-year follow-up study in Taiwan

PURPOSE

The impact of epilepsy following different subtypes of stroke is unclear. The aim of this study was to evaluate the risk of post-stroke epilepsy with different stroke subtypes.

METHODS

A total of 4126 stroke patients and 24,756 age- and sex-matched controls were retrieved from the Longitudinal Health Insurance Database 2005, a major dataset of the National Health Insurance Research Database, from 2000 to 2003. All were then individually tracked to their last medical visit up to five years from 30 days after their first-ever stroke incident to identify those who developed epilepsy.

RESULTS

Among the 4126 stroke patients, 72.2% had ischemic stroke, 14.7% had intracerebral hemorrhage (ICH), 2.3% had subarachnoid hemorrhage (SAH), 2.0% had other and unspecified intracranial hemorrhage (OIH), including subdural hemorrhage and epidural hemorrhage, and 8.9% had multiple stroke subtypes. The adjusted hazard ratio for the development of epilepsy was 11.5 (95% CI 8.2-16.2) for the patients with stroke compared to the controls. 2.6% of the patients with stroke developed epilepsy during the 5-year follow-up period. The rate of post-stroke epilepsy was highest in patients with multiple subtypes (7.7%), followed by ICH (4.3%), SAH (4.2%), OIH (2.5%) and ischemic stroke (1.6%).

CONCLUSION

Stroke patients had a significantly higher risk of developing epilepsy than the controls. The risk of post-stroke epilepsy was higher in patients with hemorrhagic stroke than ischemic stroke.

Acute seizures in acute ischemic stroke: does thrombolysis have a role to play?

Seizures appear at stroke presentation, during the acute phase or as a late complication of stroke. Thrombolysis has not been investigated as a risk factor despite its potential neurotoxic effect. We try to identify risk factors for seizures during the acute phase of ischemic stroke in a cohort including thrombolysed patients. We undertook a case-control study at a single stroke center using data from Acute Stroke Registry and Analyse of Lausanne (ASTRAL). Patients with seizure occurring during the first 7 days following stroke were retrospectively identified. Bi-variable and multivariable statistical analyses were applied to compare cases and randomly selected controls. We identified 28 patients experiencing from seizures in 2,327 acute ischemic strokes (1.2 %). All seizures occurred during the first 72 h. Cortical involvement, thrombolysis with rt-PA, arterial recanalization, and higher initial NIHSS were statistically associated with seizures in univariated analysis. Backward linear regression identified cortical involvement (OR 7.53, 95 % CI 1.6-35.2, p < 0.01) and thrombolysis (OR 4.6, 95 % CI 1.6-13.4, p = 0.01) as being independently associated with seizure occurrence. Overall, 3-month outcome measured by the modified Rankin scale (mRS) was comparable in both groups. In the subgroup of thrombolysed patients, outcome was significantly worse at 3 months in the seizure group with 9/12 (75 %) patients with mRS ≥ 3, compared to 6/18 (33.3 %) in the seizure-free group (p = 0.03). Acute seizures in acute ischemic stroke were relatively infrequent. Cortical involvement and thrombolysis with rt-PA are the principal risk factors. Seizures have a potential negative influence on clinical outcome in thrombolysed patients.

Early seizures in first-ever acute stroke patients in India: incidence, predictive factors and impact on early outcome

BACKGROUND AND PURPOSE

Stroke-associated early seizures (ES) often complicate the initial course of acute stroke. This study intended to estimate the rate of and the predictive factors for ES and the impact of ES on the clinical outcome in patients with first-ever acute stroke.

MATERIALS AND METHODS

Consecutive patients with first-ever acute stroke admitted in the Department of Medicine from June 2010 to December 2011 were prospectively included. ES were defined as seizures occurring within 7 days from acute stroke. Patients with history of epilepsy, transient ischaemic attack, subarachnoid haemorrhage and cerebral venous thrombosis were excluded. Clinical outcomes were measured under the subheadings of mortality and disability at discharge, according to modified Rankin score.

RESULTS

Of the 441 (56.92% male patients, median age 55 years, 49.43% had haemorrhagic stroke) patients, 79 (17.91%, 95% confidence interval (CI): 14.61-21.78%) suffered from ES. At discharge, 37.64% were disabled, and 19.5% were dead. In multivariate analysis, alcoholism, NIHSS at admission, haemorrhagic stroke and cortical location were significant predictors of ES. Thirty-day mortality was predicted by NIHSS at admission [hazard ratio (HR): 1.14, 95% CI: 1.11-1.18, P < 0.001], history of hypertension (HR: 3.79, 95% CI: 2.1-6.85, P < 0.001), history of alcoholism (HR: 2.43, 95% CI: 1.49-3.95, P < 0.001) and early seizure (HR: 2.58, 95% CI: 1.54-4.34, P = 0.001).

CONCLUSIONS

Early seizures occurred in about 18% acute stroke patients. Alcoholism, haemorrhagic stroke, cortical and severe strokes predict development of ES. ES are an independent important risk factor for early mortality.

Epilepsy in the elderly: facts and challenges

The incidence of epilepsy in the elderly has increased steadily over the last few decades. In some industrialized countries, one-third of the population is expected to be over the age of 65 in 2030. Therefore, we will face a dramatic increase in the number of elderly patients with epilepsy, many of whom will likely present comorbidities. This increase will put a heavy burden on health care and pension systems. This article focuses on epidemiology, diagnosis and treatment in epilepsies in the elderlies and outlines current research as well as future requirements for research. The diagnosis of epilepsy in the elderly can be difficult and may require long-term video-EEG monitoring. Stroke is the most frequent etiology in epilepsies in the elderlies. Status epilepticus in acute symptomatic epilepsies often results in fatality and may become an increasing health problem. The article also describes the current strategies in antiepileptic drug treatment and epilepsy surgery in the elderly. Novel antiepileptic drugs are necessary as current antiepileptics have strong interaction potentials and harmful side effects, making them ill-suboptimal for treating epilepsy in the elderly.

Neurological complications of acute ischaemic stroke

Complications after ischaemic stroke, including both neurological and medical complications, are a major cause of morbidity and mortality. Neurological complications, such as brain oedema or haemorrhagic transformation, occur earlier than do medical complications and can affect outcomes with potential serious short-term and long-term consequences. Some of these complications could be prevented or, when this is not possible, early detection and proper management could be effective in reducing the adverse effects. However, there is little evidence-based data to guide the management of these neurological complications. There is a clear need for improved surveillance and specific interventions for the prevention, early diagnosis, and proper management of neurological complications during the acute phase of stroke to reduce stroke morbidity and mortality.

Efficacy of 3,5-dibromo-L-phenylalanine in rat models of stroke, seizures and sensorimotor gating deficit

BACKGROUND AND PURPOSE

Abnormal glutamatergic activity is implicated in neurologic and neuropsychiatric disorders. Selective glutamate receptor antagonists were highly effective in animal models of stroke and seizures but failed in further clinical development because of serious side effects, including an almost complete set of symptoms of schizophrenia. Therefore, the novel polyvalent glutamatergic agent 3,5-dibromo-L-phenylalanine (3,5-DBr-L-Phe) was studied in rat models of stroke, seizures and sensorimotor gating deficit.

EXPERIMENTAL APPROACH

3,5-DBr-L-Phe was administered intraperitoneally as three boluses after intracerebral injection of endothelin-1 (ET-1) adjacent to the middle cerebral artery to cause brain injury (a model of stroke). 3,5-DBr-L-Phe was also given as a single bolus prior to pentylenetetrazole (PTZ) injection to induce seizures or prior to the administration of the N-methyl-D-aspartate (NMDA) receptor antagonist dizocilpine (MK-801) to cause disruption of prepulse inhibition (PPI) of startle (sensorimotor gating deficit).

KEY RESULTS

Brain damage caused by ET-1 was reduced by 52%, which is comparable with the effects of MK-801 in this model as reported by others. 3,5-DBr-L-Phe significantly reduced seizures induced by PTZ without the significant effects on arterial blood pressure and heart rate normally caused by NMDA antagonists. 3,5-DBr-L-Phe prevented the disruption of PPI measured 3 days after the administration of ET-1. 3,5-DBr-L-Phe also eliminated sensorimotor gating deficit caused by MK-801.

CONCLUSION AND IMPLICATIONS

The pharmacological profile of 3,5-DBr-L-Phe might be beneficial not only for developing a therapy for the neurological and cognitive symptoms of stroke and seizures but also for some neuropsychiatric disorders.

[Seizures and epilepsies after stroke]

Epilepsies after stroke represent 20% of all adult-onset epilepsies and exhibit special characteristics with respect to diagnosis, treatment, and prognosis. Patients are frequently amnestic for their seizures the signs of which can be very subtle. Postictal pareses and confusional states can last for days, which further complicate diagnosis. Single seizures after stroke were reported in 2% to 10% of cases, and community-based studies found epilepsies in 3% to 4% of stroke patients. Analyses of subgroups identified epilepsy risks of 3% after ischemic infarction, 6% to 10% after intracerebral hemorrhage, and 9% after subarachnoid hemorrhage. Status epilepticus developed in less than 1% of stroke patients. Besides etiology, further risk factors for epilepsy comprise: remote seizures (latency >2 weeks, risk of recurrence >50%) more than early seizures (latency <2 weeks, risk of recurrence <50%), extent of stroke, cortical involvement, and degree of neurological deficit. The first appearance of seizures in patients older than 60 years represents a risk factor for future stroke with a hazard ratio of 2.89.There is currently no sufficient evidence for starting AED treatment before seizures occur. The benefit is still unclear of starting AED after a single early post-stroke seizure. Most authors recommend AED treatment after the second seizure but also after a first remote seizure because of the high risk of seizure recurrence in these situations. Possible pharmacokinetic interactions should be considered when choosing AED. Especially the first-generation AED carry the potential to interact with comedication, which is usually seen in stroke patients receiving substances such warfarin and salicylates. Only very few studies investigate specific AED exclusively in stroke patients. Lamotrigine and gabapentin have been successfully tested in these patients.

Early seizures in cerebral vein and dural sinus thrombosis: risk factors and role of antiepileptics

BACKGROUND AND PURPOSE

The risk of seizure early after the diagnosis of cerebral vein and dural sinus thrombosis (CVT) is not known, and the use of prophylactic antiepileptic (AED) medication in the acute phase of CVT is controversial.

METHODS

In a multicenter, prospective, observational study, we analyzed the risk factors for seizures experienced before the diagnosis of CVT was confirmed (presenting seizures) or within the following 2 weeks (early seizures). The risk of occurrence of early seizures was compared in 4 risk strata and related to whether patients received AEDs or not. Criteria for the strata were "presenting seizures" and "supratentorial lesions."

RESULTS

Two hundred forty-five of 624 (39.3%) patients with CVT experienced presenting seizures, and 43 (6.9%) patients had early seizure. In logistic-regression analysis, supratentorial lesion (odds ratio [OR]=4.05, 95% CI=2.74 to 5.95), cortical vein thrombosis (OR=2.31, 95% CI=1.44 to 3.73), sagittal sinus thrombosis (OR=2.18, 95% CI=1.50 to 3.18), and puerperal CVT (OR=2.06, 95% CI=1.19 to 3.55) were associated with presenting seizures, whereas supratentorial lesion (OR=3.09, 95% CI=1.56 to 9.62) and presenting seizures (OR=1.74, 95% CI=0.90 to 3.37) predicted early seizures. The risk of early seizures in patients with supratentorial lesions and presenting seizures was significantly lower when AED prophylaxis was used (1 with seizures in 148 patients with AEDs vs 25 in 47 patients without AEDs; OR=0.006, 95% CI=0.001 to 0.05).

CONCLUSIONS

CVT patients with supratentorial lesions had a higher risk for both presenting and early seizures, whereas patients with presenting seizures had a higher risk of recurrent seizures within 2 weeks. Our results support the prescription of AEDs in acute CVT patients with supratentorial lesions who present with seizures.

Incidence of seizures in the acute phase of stroke: a population-based study

PURPOSE

The incidence of seizures within 24 h of acute stroke has not been studied extensively. We aimed to establish the incidence of acute poststroke seizures in a biracial cohort and to determine whether acute seizure occurrence differs by race/ethnicity, stroke subtype, and/or stroke localization.

METHODS

We identified all stroke cases between July 1993 and June 1994 and in 1999 within the population of the Greater Cincinnati metropolitan region. Patients with a prior history of seizures/epilepsy were excluded from analysis.

RESULTS

A total of 6044 strokes without a history of seizure(s) were identified; 190 (3.1%) had seizures within the first 24 h of stroke onset. Of ICH/SAH patients, 8.4% had a seizure within the first 24 h of stroke onset (p <or= 0.0001 vs. all other stroke subtype). Of the patients with ischemic stroke, we observed higher incidence of seizures in cardioembolic versus small or large vessel ischemic (p = 0.02) strokes. Patients with seizures experienced higher mortality than patients without seizures (p < 0.001) but seizures were not an independent risk factor of mortality at 30 days after stroke. Independent risk factors for seizure development included hemorrhagic stroke, younger age, and prestroke Rankin score of >or=1. Race/ethnicity or localization of the ischemic stroke did not influence the risk for seizure development in the studied population.

DISCUSSION

The overall incidence of acute seizures after stroke was 3.1%, with a higher incidence seen in hemorrhagic stroke, younger patients, and those presenting with higher prestroke Rankin scores. Acute seizures were associated with a higher mortality at 30 days after stroke.

Neuropsychological features of lesion-related epilepsy in adults: an overview

Lesional epilepsy is thought to be a direct consequence of focal brain lesions of dysgenetic, neoplastic, vascular, or traumatic origin. It has been estimated that at least half of all epilepsies are the result of such lesions. The current discussion includes an overview of the cognitive and behavioral presentations in adults with epilepsy secondary to focal pathology. The neuropsychological presentation in this population is influenced by many factors, including the location and nature of the underlying lesion, seizure characteristics, the effects of treatment, and patient variables. Few studies attempt to disentangle the specific contributions of these variables to cognitive performance. However, where available studies examining the separable effects of seizure-related variables on cognitive functioning in individuals with lesional epilepsy are also reviewed. This overview includes a discussion of focal malformations of cortical and vascular development and select foreign tissue and acquired lesions.

Update on intracerebral haemorrhage

Intracerebral haemorrhage (ICH) is a common and serious disease. About 1 to 2 out of 10 patients with stroke have an ICH. The mortality of ICH is higher than that of ischaemic stroke. Only 31% are functionally independent at 3 months. Only 38% of the patients survive the 1(st) year. The cost of ICH is high. Hypertension is the major risk factor, increasing the risk of ICH about 4x. Up to half of hypertensive patients who suffer a ICH are either unaware of their hypertension, non-compliant with the medication or fail to control periodically their blood pressure levels Microbleeds and white matter changes are MRI markers of the risk of ICH. ICH has 3 main pathophysiological phases: arterial rupture and haematoma formation, haematoma enlargement and peri-haematoma oedema. Up to 40% of the haematomas grow in the first hours post-rupture. ICH growth is associated with early clinical deterioration. Two randomised clinical trials (RCTs) demonstrated that treatment with rFVIIa limited haematoma growth and improved outcome, but was associated with a increase in thromboembolic complications. Ventricular drainage with thrombolytics might improve outcome for patients with intraventricular bleeding. A large RCT and meta-analysis failed to show a benefit of surgery over conservative treatment in acute ICH.

Computed tomographic changes of the brain and clinical outcome of patients with seizures and epilepsy after an ischaemic hemispheric stroke

It is not well established whether seizures and epilepsy after an ischaemic stroke increase the disability of patients. Seventy-two patients with delayed seizures after a hemispheric infarct (37 with a single seizure and 35 with epilepsy) were included in the study. The modified Rankin scale was used to compare disability of the patients at 1 month after stroke and at 2 weeks after single or the last seizure, in case of epilepsy. The size of the X-ray hypoattenuation zone was compared on computed tomographic (CT) scans, performed in the weeks after the stroke and 1 week after single or repeated seizures. Lesion size was determined by superimposing the CT slices on digital cerebral vascular maps, on which the contours of the infarct area were delineated. The extent of the infarcts was expressed as the percentage fraction of the total surface area of the cerebral hemisphere. Groups with a single seizure and with epilepsy were mutually compared. Infarcts predominated in the parieto-temporal cortical regions. In the overall group the median Rankin score worsened significantly after seizures. The average size of the X-ray hypoattenuation zone was also significantly increased on the CT scans after the seizures, compared with those after stroke, without clear evidence of recent infarction. Mutual comparison of patients with a single seizure episode and of those with epilepsy showed only a trend of more severe disability and of increase in lesion size in the post-stroke epilepsy group. Delayed seizures and epilepsy after ischaemic stroke are accompanied by an increase in lesion size on CT and by worsening of the disability of the patients. This study does not allow to determine whether this is due to stroke recurrence or due to additional damage as a result of the seizures themselves.