From the Guidelines
Prophylactic antiseizure medications are not recommended routinely after an MCA stroke, as current evidence does not support the use of preventive anticonvulsants in patients who have not experienced seizures following stroke. The decision to start prophylaxis should be individualized based on specific risk factors such as cortical involvement, large stroke size, or hemorrhagic transformation, which increase seizure risk 1. If a patient does experience a seizure after an MCA stroke, then treatment with antiepileptic drugs would be indicated, typically starting with levetiracetam (500-1000 mg twice daily) or lamotrigine (25-50 mg daily, gradually titrated up) 1. These medications are preferred due to their favorable side effect profiles and minimal drug interactions. The rationale behind avoiding routine prophylaxis is that most stroke patients will not develop seizures, and unnecessary medication exposure carries risks of adverse effects, drug interactions, and additional medication burden. If seizures do occur, prompt treatment is essential, and the duration of therapy would typically be at least 3-6 months, with consideration for longer treatment if seizures recur. Key considerations include:
- Monitoring for recurrent seizure activity in patients with a history of post-stroke seizures 1
- Individualized treatment approaches based on patient-specific factors and clinical judgment 1
- Avoiding routine prophylactic administration of anticonvulsant medications due to potential harm and negative effects on neurological recovery 1
From the Research
Seizure Prophylaxis after MCA Stroke
The recommended prophylaxis for seizures after a middle cerebral artery (MCA) stroke is a topic of ongoing research and debate.
- The use of antiepileptic drugs (AEDs) for primary prevention of seizures after stroke has been investigated in several studies 2, 3.
- A study published in 2023 proposed a randomized controlled trial to assess the effectiveness of low-dose AEDs (levetiracetam or perampanel) in preventing poststroke epilepsy in patients with MCA infarction 2.
- However, a 2017 guideline by the European Stroke Organisation suggested that AEDs should not be administered routinely for primary prevention of poststroke seizures, due to the lack of evidence from adequately powered randomized controlled trials 4.
- A 2022 Cochrane review found that AEDs were not effective in primary prophylaxis of poststroke seizure, but the evidence was of low to moderate certainty 3.
- Some studies have suggested that newer generation AEDs, such as levetiracetam, may be effective in reducing the incidence of seizures after stroke, particularly in patients with cortical involvement 5, 6.
Antiepileptic Drugs for Seizure Prophylaxis
The choice of AED for seizure prophylaxis after MCA stroke depends on various factors, including the patient's age, comorbidities, and potential drug interactions.
- Newer generation AEDs, such as levetiracetam, gabapentin, and lamotrigine, may be preferred due to their improved safety profile and fewer interactions with other drugs 5.
- A 2020 study found that prophylactic use of levetiracetam reduced the odds of new seizure events after intracerebral hemorrhage, independently of the admission NIHSS score and the presence of cortical involvement 6.
Future Research Directions
Further research is needed to determine the optimal strategy for seizure prophylaxis after MCA stroke, including the type and duration of AED therapy.