Admission and Discharge Instructions for Patients with History of Stroke and Seizures
Patients with a history of stroke and seizures should be monitored closely for neurological changes, seizure recurrence, and complications during hospitalization, with clear discharge instructions addressing medication management, follow-up care, and seizure precautions.
Admission Instructions
Neurological Monitoring
- Assess level of consciousness, neurological status, and vital signs at least hourly during the acute phase; more frequently as the patient's condition requires 1
- Use standardized stroke scales such as the National Institutes of Health Stroke Scale (NIHSS) or Canadian Neurological Scale (CNS) to monitor for changes 1
- Report any deterioration in neurological status immediately to the stroke team for re-evaluation 1
- Monitor for changes in drowsiness/consciousness, CNS score changes ≥1 point, or NIHSS score changes ≥4 points 1
Seizure Management
- For new-onset seizures in acute stroke patients that are not self-limiting, treat with appropriate short-acting medications (e.g., lorazepam IV) 1, 2
- A single, self-limiting seizure occurring at stroke onset or within 24 hours should not be treated with long-term anticonvulsant medications 1, 2
- Monitor for recurrent seizure activity during routine monitoring of vital signs and neurological status 1, 2
- Prophylactic use of anticonvulsant medications in stroke patients is not recommended as there is evidence suggesting possible harm with negative effects on neural recovery 1, 2
Diagnostic Workup
- Complete brain imaging with non-contrast CT or MRI for all patients with suspected acute stroke 1
- Perform EEG for patients with altered mental status or depressed mental status out of proportion to the stroke 1
- Conduct acute blood work including electrolytes, random glucose, complete blood count, coagulation status (INR, aPTT), and creatinine 1
Additional Care Considerations
- Keep patients NPO (nothing by mouth) until dysphagia screening is completed within 4-24 hours by a trained nurse 1
- Implement intensive oral hygiene protocols to reduce the risk of stroke-associated pneumonia 1
- Avoid indwelling urinary catheters when possible to reduce risk of urinary tract infections 1
Discharge Instructions
Medication Management
- For patients who experienced a first unprovoked seizure with a remote history of brain disease or injury (including stroke), antiepileptic medication may be initiated or deferred in coordination with neurologists 1
- Patients with recurrent seizures should be treated according to standard seizure management protocols 1, 2
- The choice of antiepileptic drug should consider side effect profiles that may impact stroke recovery 2
- Clearly explain medication dosing, timing, and potential side effects 1
Follow-up Care
- Schedule follow-up appointments with neurology within 1-4 weeks 1, 3
- Arrange for outpatient EEG if indicated for patients with seizures 1, 2
- Ensure reliable follow-up is available if neuroimaging is deferred to outpatient setting 1
- Consider referrals to rehabilitation services as needed (physical therapy, occupational therapy, speech therapy) 1
Seizure Precautions and Education
- Educate patients and caregivers about seizure recognition, first aid, and when to seek emergency care 3
- Provide information about seizure triggers to avoid (sleep deprivation, alcohol, missed medications) 3, 4
- Advise on safety precautions (avoiding swimming alone, heights, operating dangerous machinery) until seizure-free for an appropriate period 3
- Explain the difference between early seizures (within 7 days of stroke) and late seizures (after 7 days), as late seizures have a higher risk of recurrence 3, 4
Warning Signs Requiring Medical Attention
- New or worsening neurological symptoms 1
- Recurrent seizures or seizures lasting more than 5 minutes 1
- Difficulty swallowing or signs of aspiration 1
- Fever, which could indicate infection 1
- Significant changes in mental status 1
Special Considerations
For Patients with First-Time Seizures
- Emergency physicians need not admit patients with a first unprovoked seizure who have returned to their clinical baseline 1
- Patients with seizures occurring at stroke onset have a poorer prognosis in the first 2 days but may not require long-term anticonvulsant therapy if they survive without recurrence 5
For Patients with Recurrent Seizures
- Long-term antiseizure medication is typically indicated for patients with late post-stroke seizures (occurring after 7 days from stroke onset) due to high recurrence risk 3, 4
- Approximately 30% of patients with post-stroke seizure concerns may continue antiseizure medications long-term 6