Seizures and Epilepsy After Stroke: Epidemiology, Biomarkers and Management

Abstract

Stroke is the leading cause of seizures and epilepsy in older adults. Patients who have larger and more severe strokes involving the cortex, are younger, and have acute symptomatic seizures and intracerebral haemorrhage are at highest risk of developing post-stroke epilepsy. Prognostic models, including the SeLECT and CAVE scores, help gauge the risk of epileptogenesis. Early electroencephalogram and blood-based biomarkers can provide information additional to the clinical risk factors of post-stroke epilepsy. The management of acute versus remote symptomatic seizures after stroke is markedly different. The choice of an ideal antiseizure medication should not only rely on efficacy but also consider adverse effects, altered pharmacodynamics in older adults, and the influence on the underlying vascular co-morbidity. Drug-drug interactions, particularly those between antiseizure medications and anticoagulants or antiplatelets, also influence treatment decisions. In this review, we describe the epidemiology, risk factors, biomarkers, and management of seizures after an ischaemic or haemorrhagic stroke. We discuss the special considerations required for the treatment of post-stroke epilepsy due to the age, co-morbidities, co-medication, and vulnerability of stroke survivors.

Fig. 1

Prediction of remote symptomatic seizures after ischaemic stroke using the SeLECT score. a Calculation of the SeLECT score; b Kaplan–Meier estimate curves of the risk of remote symptomatic seizures according to different SeLECT values. The risk of remote symptomatic seizures after c 1 year and d 5 years. Reproduced from Galovic et al. [19] with permission

Fig. 2

Prediction of remote symptomatic seizures after intracerebral haemorrhage using the CAVE score. a Calculation of the CAVE score; b risk of remote symptomatic seizures according to CAVE score during follow-up in the derivation and validation cohorts. For details see Sect. 3

Fig. 3

Epileptiform electroencephalogram (EEG) findings in stroke survivors. a EEG in a patient with acute right-hemispheric stroke affecting the middle cerebral artery territory. Findings on source montage include focal slow wave activity over the right medial temporal region (T4 electrode) and epileptiform activity (a spike wave marked with a black arrow). b EEG and corresponding spike source localization on the right in a patient with acute right-hemispheric stroke affecting the middle cerebral artery territory. Findings on source montage include slow wave activity over the right anterior and medial temporal regions (F8 and T4 electrodes) and right temporal (T4 electrode) epileptiform activity (sharp wave marked with a black square) with corresponding source localization on the right

Fig. 4

Blood biomarkers of acute and remote symptomatic seizures after stroke. Radar charts of z-scores for biomarkers of a acute or b remote symptomatic seizures. ApoCIII apolipoprotein CIII, FasL Fas ligand, GroA growth-related oncogene α, Hsc70 heat shock 70 kDa protein-8, IGFBP-3 insulin-like growth factor binding protein-3, IL-6 interleukin 6, NCAM neural cell adhesion molecule, NT-proBNP N-terminal Pro-B-type natriuretic peptide, S100B S100 calcium-binding protein B, TNF tumour necrosis factor, VAP-1 vascular adhesion protein-1, vWF von Willebrand factor. Reproduced from Abraira and colleagues [56, 59] with permission

Fig. 5

Prediction of seizure recurrence after antiseizure medication withdrawal. Nomogram to predict seizure recurrence risk after 2 or 5 years following antiseizure medication withdrawal. The nomogram is not specific to post-stroke epilepsy. Reproduced from Lamberink et al. [133] with permission