When should patients with first-time seizures and a history of stroke be admitted to the hospital?

Hospital Admission for First-Time Seizures in Patients with History of Stroke

Patients with first-time seizures and a history of stroke should be admitted to the hospital if they have abnormal neurological examination, have not returned to baseline, or have risk factors for early seizure recurrence such as age ≥40 years, alcoholism, hyperglycemia, or Glasgow Coma Scale score <15. 1, 2

Admission Criteria for Post-Stroke Seizures

Factors Requiring Admission

• Patients with abnormal neurological examination or who have not returned to baseline 1, 2
• Presence of risk factors for early seizure recurrence:
  • Age ≥40 years 2
  • Alcoholism 2
  • Hyperglycemia 2
  • Glasgow Coma Scale score <15 2
• Evidence of acute intracranial process on neuroimaging 1
• Cortical involvement, especially with hemorrhagic transformation (6.5 times higher risk of early seizures) 3
• Status epilepticus or multiple seizures without return to baseline 2
• Inability to maintain oral intake or concerns about swallowing function 4

Patients Who May Not Require Admission

• Patients with a first unprovoked seizure who have returned to their clinical baseline in the ED 1
• Normal neurological examination 5
• No evidence of acute intracranial process on neuroimaging 1
• Reliable follow-up available for deferred outpatient neuroimaging 1

Risk Assessment for Seizure Recurrence

Early Seizure Recurrence

• Mean time to first seizure recurrence is 121 minutes (median 90 minutes) 2
• 85% of early seizures recur within 6 hours 2
• Early-onset seizures (within first 7 days after stroke) are associated with higher risk for status epilepticus recurrence and higher mortality rates 6

Long-term Recurrence Risk

• Late-onset seizures (>14 days after stroke) have significantly higher recurrence rates than early-onset seizures (≤14 days) 7
• Patients with remote symptomatic seizures (including post-stroke) have a higher risk of seizure recurrence, with approximately three-quarters experiencing recurrence within 5 years 1

Neuroimaging Considerations

• When feasible, perform neuroimaging of the brain in the ED on patients with a first-time seizure 1
• Head CT should be performed emergently when an acute intracranial process is suspected, particularly in patients with:
  • History of acute head trauma
  • History of malignancy
  • Immunocompromised status
  • Fever
  • Persistent headache
  • History of anticoagulation
  • New focal neurologic examination
  • Age older than 40 years
  • Focal onset before generalization 1, 2
• Deferred outpatient neuroimaging may be used when reliable follow-up is available 1, 5

Management During Admission

• Keep patient NPO until swallowing screening is completed to prevent aspiration 4
• Perform swallowing screening using a validated tool as soon as possible 4
• Consider alternative routes for medication administration while patient is NPO 4
• Monitor for changes in neurological status 4, 5
• Identify and treat any precipitating medical conditions 1

Common Pitfalls to Avoid

• Failing to recognize that early-onset seizures (within 7 days of stroke) carry different prognostic implications than late-onset seizures 6, 7
• Allowing oral intake too early before proper swallowing assessment, which can lead to aspiration pneumonia 4
• Overlooking hemorrhagic transformation of ischemic stroke, which is an independent predictive factor for early seizures 3
• Assuming all post-stroke seizures carry the same risk of recurrence (late-onset seizures have higher recurrence risk) 7

By following these guidelines, clinicians can make appropriate decisions regarding hospital admission for patients with first-time seizures and a history of stroke, balancing the risks of seizure recurrence against the benefits of hospitalization.