What is the management of seizures in post-stroke patients?

Management of Post-Stroke Seizures

New-onset seizures in patients with acute stroke should be treated using appropriate short-acting medications (e.g., lorazepam IV) if they are not self-limiting, while prophylactic use of anticonvulsant medications in stroke patients without seizures is not recommended and may harm recovery. 1, 2, 3

Acute Management of Post-Stroke Seizures

• Single, self-limiting seizures occurring at the onset or within 24 hours after an ischemic stroke (immediate post-stroke seizures) should not be treated with long-term anticonvulsant medications 1, 2
• Patients who experience an immediate post-stroke seizure should be monitored for recurrent seizure activity during routine monitoring of vital signs and neurological status 1, 2
• Consider EEG monitoring in high-risk populations such as neonates, children with stroke, and adults with unexplained reduced consciousness 1, 3
• Other investigations may include tests to rule out other precipitating factors of seizures (e.g., infections) based on patient factors and clinical judgment 1

Classification of Post-Stroke Seizures

• Early seizures: occur within 7 days of stroke onset, typically due to acute metabolic disturbances and are often self-limiting 3
• Late seizures: occur beyond 7 days after stroke, indicating development of epileptogenic focus and carrying higher recurrence risk (>50%) 3, 4
• Risk factors for post-stroke seizures include:
  • Cortical involvement (higher risk compared to deep-seated hemispheric or infratentorial lesions) 3
  • Hemorrhagic stroke (10-16% incidence vs. 2-4% in ischemic stroke) 5
  • Hemorrhagic transformation of ischemic stroke 3
  • Pre-existing dementia 3

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, 2
• A single late post-stroke seizure (occurring after 7 days) carries a high risk of recurrence (up to 71.5% at ten years) and warrants consideration of antiepileptic drug therapy 4
• When selecting an antiepileptic drug for post-stroke seizures, consider:
  • Newer generation AEDs such as levetiracetam, lamotrigine, or gabapentin in low doses due to:
    • Higher rate of long-term seizure freedom 6, 7
    • Improved safety profiles 6
    • Fewer interactions with anticoagulants and other medications commonly used in stroke patients 6, 7
  • Avoid first-generation drugs such as phenytoin, carbamazepine, and phenobarbital due to:
    • Potential harmful impact on recovery 7
    • Negative effects on bone health 7
    • Cognitive impairment 6
    • Drug interactions with anticoagulants or antiplatelet agents 7

Important Considerations and Precautions

• Prophylactic use of anticonvulsant medications in patients with ischemic stroke who have not had seizures is not recommended 1, 2, 3
• Evidence suggests prophylactic AED therapy may be associated with poorer outcomes and negative effects on neurological recovery 1, 2
• Many traditional seizure medications may dampen neural plasticity mechanisms that contribute to behavioral recovery after stroke 2
• Start with low doses and titrate slowly when initiating AED therapy in stroke patients 6
• For patients requiring long-term therapy, levetiracetam starting at low doses (500-1000 mg/day) is often appropriate due to its favorable side effect profile and minimal drug interactions 8, 6
• Valproate may be considered as an alternative, but requires careful monitoring of liver function and platelets, especially during the first six months of treatment 9

Monitoring and Follow-up

• Regular monitoring of seizure activity, medication side effects, and drug levels (when applicable) is essential 1
• Treatment duration remains controversial, with some evidence suggesting that antiepileptic treatment after first post-stroke seizure decreases recurrence risk during treatment but does not alter long-term seizure risk after discontinuation 10
• Consider tapering and discontinuing AEDs after 2 years of seizure freedom in selected patients with low recurrence risk 10, 6