What is the recommended treatment for a seizure after a stroke?

Management of Post-Stroke Seizures

For patients experiencing seizures after a stroke, the recommended treatment is to use standard seizure management approaches, including appropriate short-acting medications for acute seizures and standard antiepileptic drugs (AEDs) for recurrent seizures, while avoiding prophylactic AED use in patients who have not had seizures.

Acute Management of Post-Stroke Seizures

• New-onset seizures in admitted patients with acute stroke should be treated using appropriate short-acting medications (e.g., lorazepam IV) if they are not self-limiting 1
• A single, self-limiting seizure occurring at the onset or within 24 hours after an ischemic stroke (considered an "immediate" post-stroke seizure) should not be treated with long-term anticonvulsant medications 1
• Patients who have an immediate post-stroke seizure should be monitored for recurrent seizure activity during routine monitoring of vital signs and neurological status 1

Treatment Approach for Recurrent Seizures

• Recurrent seizures in patients with ischemic stroke should be treated as per treatment recommendations for seizures in other neurological conditions 1
• Any patient who develops a seizure should be treated with standard management approaches, including a search for reversible causes of seizure in addition to potential use of antiepileptic drugs 1
• The choice of AED should consider:
  • Drug interactions with other medications commonly used in stroke patients 2
  • Side effect profiles that may impact recovery 1
  • Age-related factors in elderly patients 3, 4

Medication Selection

• Newer-generation AEDs such as levetiracetam may be preferable for post-stroke seizures, especially in elderly patients, due to:

  • High rates of seizure freedom (76-82.4% of patients become seizure-free) 3, 4, 5
  • Favorable side effect profiles 3, 4
  • Fewer drug interactions compared to older AEDs 2
  • Effective at doses of 1000-2000 mg daily 3, 4

• Traditional AEDs like valproate can be effective but require careful dosing:

  • Starting dose of 10-15 mg/kg/day, increasing by 5-10 mg/kg/week to achieve optimal clinical response 6
  • Target therapeutic plasma concentrations between 50-100 μg/mL 6
  • Divided doses if total daily dose exceeds 250 mg 6

Important Considerations and Precautions

• Prophylactic use of anticonvulsant medications in patients with ischemic stroke who have not had seizures is not recommended 1
• Evidence suggests that prophylactic AED therapy may be associated with poorer outcomes and negative effects on neurological recovery 1
• Many traditional seizure medications (phenytoin, benzodiazepines) may dampen neural plasticity mechanisms that contribute to behavioral recovery after stroke 1
• The reported frequency of seizures during the first days after stroke ranges from 2% to 23%, with the true risk likely toward the lower end of this range 1
• Seizures are more common with hemorrhagic stroke or when the stroke involves cerebral cortex; seizures in patients with lacunar stroke are rare 1

Special Considerations for Elderly Patients

• Post-stroke seizures are particularly common in elderly patients, with previous stroke accounting for 30-40% of all epilepsy cases in the elderly 2
• For elderly patients with post-stroke seizures, levetiracetam monotherapy has shown good efficacy:
  • 76-82.4% of patients become seizure-free at doses of 1000-2000 mg/day 3, 4, 5
  • Generally well-tolerated with manageable side effects 3, 4, 5
• When using AEDs in elderly patients:
  • Start at lower doses and titrate slowly 2
  • Monitor for cognitive effects and drug interactions 2
  • Consider bone health, especially with enzyme-inducing AEDs 2

Monitoring and Follow-up

• Patients with post-stroke seizures should be monitored for:
  • Recurrent seizures 1
  • Medication side effects 3, 2
  • Drug interactions, especially with anticoagulants 2
• Consider EEG and other investigations to rule out other precipitating factors of seizures (e.g., infections) in acute stroke patients with seizures 1