From the Guidelines
Seizure management in stroke patients should prioritize prompt recognition and treatment with short-acting medications, such as lorazepam IV, for acute seizures, while prophylactic anticonvulsant medications are not recommended due to potential harm and negative effects on neurological recovery. The management of seizures in stroke patients is crucial to prevent further brain injury and improve outcomes. According to the most recent guidelines, new-onset seizures in admitted patients with acute stroke should be treated using appropriate short-acting medications, such as lorazepam IV, if they are not self-limiting 1.
Key Considerations
- A single, self-limiting seizure occurring at the onset or within 24 hours after an ischemic stroke should not be treated with long-term anticonvulsant medications 1.
- Patients with immediate post-stroke seizures should be monitored for recurrent seizure activity, and recurrent seizures should be treated as per treatment recommendations for seizures in other neurological conditions 1.
- Prophylactic use of anticonvulsant medications in patients with ischemic stroke is not recommended, with evidence suggesting possible harm and negative effects on neurological recovery 1.
Treatment Approach
For acute seizures following stroke, immediate administration of intravenous benzodiazepines, such as lorazepam 2-4 mg IV, is recommended. If seizures persist, second-line therapy includes fosphenytoin or levetiracetam. For long-term management after a post-stroke seizure, levetiracetam is often preferred due to its favorable side effect profile and minimal drug interactions. Regular monitoring of drug levels, electrolytes, and liver function is essential.
Special Populations
Seizures are a common presentation with stroke in neonates and children, and enhanced or increased seizure/electroencephalogram monitoring may be considered in at-risk populations, such as neonates, children with stroke, and adults with otherwise unexplained reduced level of consciousness 1. Other investigations, including EEG and tests to rule out other precipitating factors of seizures, may be warranted in acute stroke patients with seizures based on patient factors and clinical judgment 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Seizure Management in Stroke Patients
- Seizure after stroke or poststroke seizure (PSS) is a common and important complication of stroke, accounting for about 11% of all adult epilepsy cases and 45% of epilepsy cases over 60 years of age 2.
- The risk of PSS is higher in patients with hemorrhagic stroke, cortical involvement, severity of initial neurological deficit, younger patients (<65 years of age), family history of seizures, and certain genetic factors 2.
- The use of continuous electroencephalogram has demonstrated significant benefits in capturing interictal or ictal abnormalities, especially in cases of non-convulsive seizures and non-convulsive status epilepticus 2.
Antiepileptic Drug (AED) Treatment
- Current available data indicated that there was no significant difference in antiepileptic efficacy among most of the antiepileptic drugs (AEDs) in PSS 2.
- Levetiracetam and lamotrigine are the most studied newer generation AEDs and have the best drug tolerance 2.
- The latest studies regarding post-stroke seizure treatment showed that 'new-generation' drugs, such as lamotrigine, gabapentin, and levetiracetam, in low doses would be reasonable because of their high rate of long-term seizure-free periods, improved safety profile, and fewer interactions with other drugs 3.
Levetiracetam Dosing
- Patients receiving a 1000-mg total daily dose of levetiracetam had a higher seizure incidence than those receiving >1000-mg total daily dose 4.
- Patients may experience a reduced incidence of clinical and electroencephalographic seizures with levetiracetam dosing >1000-mg total daily dose 4.
Comparison of AEDs
- Levetiracetam might be more effective than phenytoin for the treatment of established status epilepticus and is associated with a lower incidence of more serious adverse events 5.
- Levetiracetam can be used as an alternative to phenytoin for the treatment of benzodiazepine-refractory status epilepticus 5.
- Valproic acid (VPA) failed to control status epilepticus in 25.4%, phenytoin (PHT) in 41.4%, and levetiracetam (LEV) in 48.3% of episodes in which these were prescribed 6.