MANAGEMENT OF

STROKE-RELATED SEIZURE

Dr. dr. PUJI PINTA O. SINURAT, Sp.S (K)

Webinar Perdossi
Epilepsi Update I

August 8th 2020 1

OUTLINE

 Introduction
 Terminology
 Incidence
 Risk Factors
 Pathophysiology
 Clinical Manifestation
 Diagnostic Procedure
 Management
 Prognosis
 Take home message
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INTRODUCTION
 Seizure after stroke is common & very
important complication of stroke
 Stroke represents the underlying cause in
11% of all epilepsies in adults
 50% of newly diagnosed epilepsy among
patients > 60 yo
 Increased Prevalence of post-stroke
survivors  number of patients with
PSE is expected to increase

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INTRODUCTION (CONT…)

 after the first epileptic seizure 

pathological in the brain  disorganized
electrical activity  tendency for
recurrent seizures
 Late-onset seizures higher recurrence
rate and poorer prognosis
 So far, there are no reliable clinical
 practice guidelines of stroke-related
seizure management

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 INTRODUTION (CONT…)
The New 2017 ILAE Seizure Classification

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TERMINOLOGY
 Post-Stroke Seizure (PSS) = Stroke–Related Seizure:
 single or multiple convulsive episode/s after stroke and
thought to be related to reversible or irreversible
cerebral damage due to stroke regardless of time of
onset following the stroke

 International League Against Epilepsy (ILAE)

1. Early Seizures (ESs) : seizures occurring
within 7 days of onset of stroke
2. Late Seizures (LSs) : those beyond 7 days


 Note : the time cut-off for ESs versus LSs is arbitrary

 and varies among different studies

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TERMINOLOGY (CONT…)
Post Stroke Epilepsy (PSE): recurrent seizures
that met the criteria for diagnosis of epilepsy
which were not provoked by any factor
(metabolic, toxic, or any other) and occurred
after the acute phase of stroke

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INCIDENCE

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POTENTIAL RISK FACTORS OF
PSE

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PATHOMECHANISMS OF
EPILEPTOGENESIS
IN STROKE-RELATED EPILEPSY

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CLINICAL MANIFESTATION
 Focal onset
- with or without impaired awareness
(Simple /Complex Partial seizure)
- with or without motor symptoms
- with extension of bilateral tonic-
clonic seizures (secondary
generalised tonic-clonic seizures)
 Generalised onset
 Unknown onset

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CLINICAL MANIFESTATION
(CONT…)

 In Community-based cohort study (Stefanidou et

al ):
- 72% were focal onset seizures
- 28% were generalised onset seizures

 In a population-based longterm comprehensive

follow-up study (Bryndziar et al):
- 66% were focal (partial) onset seizures ,
with or without secondary generalisation.
 - 34% were generalised onset seizures, and
 - 11.4% developed into status epilepticus (SE)
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DIAGNOSTIC PROCEDURES
 EEG :
 - PLEDs (Periodic Lateralised Epileptiform
 Discharges)
 - Intermittent rhytmic delta activities (IRDAs)
 - Diffuse slowing
Brain CT Scan
Brain MRI
Diffusion-Weighted Imaging (DWI)
Blood Exam  metabolic, Toxic as provoking
factors

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MANAGEMENT
 Two major Categories :
1. Prevention and prophylactic
treatment
2. Symptomatic treatment

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Prevention and Prophylactic treatment of Stroke-
Related Seizure:

even if the risk of seizures and

epilepsy after stroke is high, the
American Heart Association (AHA)/
European Stroke Organisation (ESO)
does not recommend the prophylaxis
using AEDs in stroke survivors.

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Symptomatic treatment of Stroke-Related
Seizure:

 There are no specific evidence-based guidelines for

the medical management of seizure after stroke
 Main approach : Anti Epileptic Drugs (AEDs)
 The goal for AED therapy is seizure freedom
 There are no clear guidelines on use of AED, when
to start , which is the most effective class, dose or
how long to treat patients with AED
 Expert recommendation: use of second-generation
AED, gabapentin, levetiracetam and lamotrigine
due to low seizure recurrence and fewer side
effects and interactions

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Symptomatic treatment of Stroke-Related
Seizure: (Cont…)

 In General : MONOTHERAPY is preferred

First-line  Start Low .. Go Slow
 When seizures are resistant to first-line
therapy adding a second AED with a
differing mechanism of action
 Levetiracetam and lamotrigine are the
most studied newer generation AEDs and
have the best drug tolerance.
 In those with Pharmacoresistant  adjunc
treatment : neuromodulation, surgical, etc.
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Symptomatic treatment of Stroke-Related
Seizure: (Cont…)

 Early onset seizure does not typicaly

warrant treatment with AED
 When a patient presents with a first
unprovoked seizure shows no significant
high risk (≥60%) for recurrent seizures 
an AED treatment should be deferred
until the recurrent seizure occurs
 when a patient presents with a second or
more unprovoked recurrent seizures 
an AED treatment should be initiated
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Symptomatic treatment of Stroke-Related
Seizure: (Cont…)

 If multiple ES (within 24 hrs) occur or

ES occurs after ICH / haemorrhagic
transformation  suggested short-term
treatment (1 month) with AED (maybe
beneficial for preventing LS)
 Decision to initiate AED after LS 
individualised
 PSE should always be treated with an AED
 In case with Status Epilepticus  long-term
AED
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 ANTIEPILEPTIC DRUGS
 Most AED impair cognition
 Choice AED  individual: Concurrent
medication, medical comorbidities
 First Generation AED should be the first
choice (Carbamazepine, Phenytoin,
Phenobarbital, Valproic acid, etc)
 The newer generation AED : Fewer drug
interaction, fewer adverse reaction ,
tolerability >> : (Levetiracetam,
Lamotrigin, Gabapentin, Topiramat, etc)
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Results of the questionnaire survey on AED treatment in PSE from Japanese stroke
specialists working in 189 hospitals in FOOTER
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 2 RCTs comparing LEV with CR-CBZ & LTG with CR-CBZ to determine the
best available evidence on the efficacy and tolerability of AEDs to treat PSS and
PSE

 Results :
 No significant difference was found in seizure freedom between
LEV and CR-CBZ (p=0.08) and between LTG and CR-CBZ (p=0.06)
 Occurrence of Adverse Events was lower for LEV than CR-CBZ (p=0.02)
and for LTG than CR-CBZ (p=0.05)

 Conclusion :
 Direct and indirect comparisons did not find a difference in seizure freedom
between the various AEDs
 LEV and LTG appears better tolerated than CRCBZ
 LEV seems associated with more Adverse Events than LTG
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 TAKE HOME MESSAGES

 up to 40% of patients with epilepsy after stroke

needed to switch their first prescribed AED, mostly
because of side effects in lower dosage ranges.

 Choosing the right AED treatment is therefore

important

 Newer AEDs with lower side-effect rates might do

better in patients with PSE
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Key Points :
 Total cholesterol was higher in Carbamazepine Vs Levetiracetam
 C-reactive protein was higher in carbamazepine Vs Levetiracetam or
Lamotrigine
 Statins had markedly less effect on serum cholesterol in patients
taking
Carbamazepine VS Levetiracetam or Lamotrigine
 These results suggest that Carbamazepine may be a poor choice for
patients who are at risk for vascular disease
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PROGNOSIS
 Seizures related to stroke are harmful for patients.
 The outcome for patients with early-onset
seizures is poor with a high in-hospital mortality
rate.
 Patients with early-onset seizures have a
recurrence rate of just 16% Vs > 50 % with Late-
onset seizures
 Recurrence of late onset seizures or post-stroke
epilepsy increases the disability of stroke patients
and promotes the occurrence of vascular
cognitive impairment

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TAKE HOME MESSAGE
 Post stroke seizure & Post stroke epilepsi :
common

 Increased Prevalence of post-stroke survivors 

increased number of patients with PSE

 There are no reliable clinical practice guidelines

of stroke-related seizure management

 Stroke-Related Seizure should be correctly

managed  Seizure freedom, improve the QOL
& avoid further deterioration of stroke patients
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