How should I manage a seizure in a patient with an acute middle cerebral artery (MCA) stroke?

Management of Seizures in Acute MCA Stroke

Treat active, non-self-limiting seizures immediately with IV lorazepam 4 mg at 2 mg/min, but do NOT start long-term anticonvulsants for a single seizure occurring within 24 hours of stroke onset. 1, 2

Acute Seizure Management Algorithm

For Active Seizures

• First-line: Administer IV lorazepam 4 mg at 2 mg/min to terminate the seizure 1, 2
• Second-line (if seizure continues): Give levetiracetam 30 mg/kg IV over 5 minutes (approximately 2000-3000 mg for average adults) 2
• Critical error to avoid: Do not use maintenance doses (500-1000 mg) as loading doses—this leads to treatment failure. Studies show 20 mg/kg doses have only 38% efficacy compared to 68-73% with 30 mg/kg doses 2

Decision Point: Long-Term Anticonvulsants

Single, self-limiting seizure within 24 hours ("immediate" post-stroke seizure):

• Do NOT initiate long-term anticonvulsants 1, 2, 3
• This recommendation is based on lack of benefit and evidence of possible harm with negative effects on neurological recovery 1
• Monitor closely for recurrence during routine vital signs and neurological checks 1

Recurrent seizures in acute period:

• Start long-term anticonvulsant therapy using standard seizure management protocols 1
• Preferred agent: Levetiracetam due to better tolerability, preserved cognitive function, and lack of drug interactions 2
• Avoid phenytoin due to association with excess morbidity, worse cognitive outcomes, and significant drug interactions 2

Monitoring Protocol During Hospitalization

Seizure Surveillance

• Assess for recurrent seizure activity at each routine vital sign check throughout hospital stay 1, 2
• Enhanced EEG monitoring (24-48 hours continuous) is indicated for patients with unexplained reduced level of consciousness disproportionate to imaging findings 1, 2
• Consider EEG to rule out non-convulsive status epilepticus when new seizures occur 2

Temperature Management

• Monitor body temperature every 4 hours for first 48 hours after stroke 2, 3
• Fever can precipitate seizures and worsens stroke outcomes 2, 3

Diagnostic Work-Up for New Seizure Events

Rule out reversible precipitating factors: 1, 2

• Obtain serum electrolytes, glucose, complete blood count, coagulation studies (INR, aPTT), and renal function tests 2
• Actively search for hypoglycemia, electrolyte abnormalities, hypoxia, infection, and medication effects 2
• Perform EEG assessment 1, 2

Critical Pitfalls to Avoid

Do NOT use prophylactic anticonvulsants: 1, 2

• Prophylactic use in patients without documented seizures is not recommended and may cause harm 1
• Evidence suggests negative effects on neural recovery and cognitive function 1, 2

Blood pressure management in MCA stroke with seizure:

• Avoid aggressive blood pressure lowering to maintain cerebral perfusion 3
• Generally do not lower systolic BP unless >220 mmHg or diastolic >120 mmHg in acute phase 3

Swallowing assessment:

• Keep patient NPO until swallowing screen completed using validated tool 1, 3
• Aspiration risk is elevated after stroke with seizure 3