Poststroke seizure: optimising its management

Abstract

Seizure after stroke or poststroke seizure (PSS) is a common and very important complication of stroke. It can be divided into early seizure and late seizure, depending on seizure onset time after the stroke. It has been reported that ischaemic and haemorrhagic stroke accounts for about 11% of all adult epilepsy cases and 45% of epilepsy cases over 60 years of age. However, there are no reliable guidelines in clinical practice regarding most of the fundamental issues of PSS management. In recent years there has been an increased interest in the study of PSS which may give clinical practitioners a better picture of how to optimise PSS management. Studies have indicated two peaks in PSS occurrence-the first day and 6-12 months after a stroke. Haemorrhagic stroke, cortical involvement, severity of initial neurological deficit, younger patients (<65 years of age), family history of seizures and certain genetic factors carry a higher risk of PSS. 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. Current available data indicated that there was no significant difference in antiepileptic efficacy among most of the antiepileptic drugs (AEDs) in PSS. Levetiracetam and lamotrigine are the most studied newer generation AEDs and have the best drug tolerance. The purpose of this review is to summarise the recent advances in PSS research and focus on the most important practice issues of PSS management.

Keywords: acute stroke; antiepileptic drugs; electroencephalography; seizures.

Figure 1

Lateralised periodic discharges (LPDs, formerly known as periodic lateralised epileptiform discharges). The EEG showed left side LPDs recurring at 0.5 Hz (discharges per second) with focal slowing in the same area. This EEG was obtained from a 61-year-old woman with left middle cerebral artery infarct and one-time generalised tonic-clonic seizure.

Figure 2

Bilateral independent periodic discharges (BIPDs, formerly known as bilateral independent periodic lateralised epileptiform discharges). The electroencephalogram (EEG) showed BIPDs are present over the bilateral temporal areas independently (unsynchronised). This EEG was obtained from a 34-year-old man with subarachnoid haemorrhage and several generalised tonic-clonic seizures.

Figure 3

Lateralised intermittent rhythmic delta activity. The electroencephalogram (EEG) showed left side (mainly left temporal lobe) brief intermittent runs of rhythmic delta activity at 1–1.5 Hz. This EEG was obtained from a 65-year-old woman with 1-year history left side middle cerebral artery stroke and intermittent altered mental status and aphasia.