From the Guidelines
Patients with post-stroke seizures (PSS) should be treated with antiepileptic drugs (AEDs) as per treatment recommendations for seizures in other neurological conditions, with first-line treatment typically including levetiracetam or lamotrigine, and prophylactic use of anticonvulsant medications is not recommended due to potential harm and negative effects on neural recovery. The management of PSS in patients with recurrent events requires a comprehensive approach, including prompt initiation of AEDs and monitoring for recurrent seizure activity. According to the Canadian Stroke Best Practice Recommendations 1, new-onset seizures in admitted patients with acute stroke should be treated using appropriate short-acting medications, such as lorazepam IV, if they are not self-limiting.
For acute seizure management, intravenous lorazepam (2-4 mg) or diazepam (5-10 mg) should be administered to stop ongoing seizures. The American Heart Association/American Stroke Association guidelines 1 also recommend that any patient who develops a seizure should be treated with standard management approaches, including a search for reversible causes of seizure and any potential antiepileptic drugs.
Some key points to consider in the management of PSS include:
- Treatment duration depends on seizure recurrence risk, with early PSS (within 7 days of stroke) potentially requiring shorter treatment (3-6 months), while late PSS (after 7 days) typically necessitates longer-term or lifelong therapy.
- Regular monitoring of drug levels, liver and kidney function, and electrolytes is essential.
- Patients should also undergo regular EEG monitoring to assess treatment efficacy.
- Addressing modifiable risk factors like hypertension, maintaining good glycemic control, and ensuring medication adherence are crucial components of comprehensive management.
- The prophylactic use of anticonvulsant medications in patients with ischemic stroke is not recommended due to potential harm and negative effects on neural recovery, as stated in the Canadian Stroke Best Practice Recommendations 1.
From the Research
Management of Post-Stroke Seizures (PSS)
The management of post-stroke seizures (PSS) involves several key considerations, including the timing of seizure onset, seizure type, and patient characteristics.
- The risk of PSS is higher in patients with hemorrhagic stroke, cortical involvement, severe initial neurological deficit, younger age (<65 years), family history of seizures, and certain genetic factors 2.
- The use of continuous electroencephalogram (EEG) can help capture interictal or ictal abnormalities, especially in cases of non-convulsive seizures and non-convulsive status epilepticus 2.
Antiepileptic Drug (AED) Treatment
The choice of AED treatment for PSS depends on several factors, including the patient's age, comorbidities, and potential drug interactions.
- Levetiracetam and lamotrigine are commonly used AEDs for PSS, with studies showing their efficacy and tolerability in elderly patients 3, 4.
- Other AEDs, such as gabapentin, may also be effective in certain patient populations 4.
- The decision to initiate AED treatment after a first or second post-stroke seizure should be individualized, based on the functional impact of the seizure episode and the patient's preference 4.
Diagnosis and Treatment of Post-Stroke Seizures and Epilepsy
The diagnosis and treatment of post-stroke seizures and epilepsy require a comprehensive approach.
- A single late post-stroke seizure carries a high risk of recurrence, and is diagnostic of post-stroke epilepsy (PSE) 5.
- Clinical and stroke characteristics, such as stroke type, location, and severity, can help identify patients at higher risk of PSS and PSE 5.
- The use of AEDs as primary prevention is not supported by current evidence, and their use in PSE is still being studied 5.
Treatment Outcomes
The outcomes of AED treatment for PSS vary depending on the patient population and treatment regimen.