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Meta-Analysis
. 2023 Nov 1;80(11):1155-1165.
doi: 10.1001/jamaneurol.2023.3240.

Outcomes in Patients With Poststroke Seizures: A Systematic Review and Meta-Analysis

Shubham Misra  1 , Scott E Kasner  2 , Jesse Dawson  3 , Tomotaka Tanaka  4 , Yize Zhao  5 , Hitten P Zaveri  6 , Ece Eldem  1 , Juan Vazquez  7 , Lucas Scárdua Silva  8 , Saba Mohidat  9 , L Brian Hickman  10 , Erum I Khan  1   11 , Melissa C Funaro  12 , John-Paul Nicolo  13   14 , Rajarshi Mazumder  10 , Clarissa Lin Yasuda  8 , Katharina S Sunnerhagen  15 , Masafumi Ihara  4 , Joseph S Ross  16 , David S Liebeskind  10 , Patrick Kwan  17 , Terence J Quinn  3 , Jerome Engel Jr  10 , Nishant K Mishra  1
Affiliations
Meta-Analysis

Outcomes in Patients With Poststroke Seizures: A Systematic Review and Meta-Analysis

Shubham Misra et al. JAMA Neurol. .

Abstract

Importance: Published data about the impact of poststroke seizures (PSSs) on the outcomes of patients with stroke are inconsistent and have not been systematically evaluated, to the authors' knowledge.

Objective: To investigate outcomes in people with PSS compared with people without PSS.

Data sources: MEDLINE, Embase, PsycInfo, Cochrane, LILACS, LIPECS, and Web of Science, with years searched from 1951 to January 30, 2023.

Study selection: Observational studies that reported PSS outcomes.

Data extraction and synthesis: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used for abstracting data, and the Joanna Briggs Institute tool was used for risk-of-bias assessment. Data were reported as odds ratio (OR) and standardized mean difference (SMD) with a 95% CI using a random-effects meta-analysis. Publication bias was assessed using funnel plots and the Egger test. Outlier and meta-regression analyses were performed to explore the source of heterogeneity. Data were analyzed from November 2022 to January 2023.

Main outcomes and measures: Measured outcomes were mortality, poor functional outcome (modified Rankin scale [mRS] score 3-6), disability (mean mRS score), recurrent stroke, and dementia at patient follow-up.

Results: The search yielded 71 eligible articles, including 20 110 patients with PSS and 1 166 085 patients without PSS. Of the participants with PSS, 1967 (9.8%) had early seizures, and 10 605 (52.7%) had late seizures. The risk of bias was high in 5 studies (7.0%), moderate in 35 (49.3%), and low in 31 (43.7%). PSSs were associated with mortality risk (OR, 2.1; 95% CI, 1.8-2.4), poor functional outcome (OR, 2.2; 95% CI, 1.8-2.8), greater disability (SMD, 0.6; 95% CI, 0.4-0.7), and increased dementia risk (OR, 3.1; 95% CI, 1.3-7.7) compared with patients without PSS. In subgroup analyses, early seizures but not late seizures were associated with mortality (OR, 2.4; 95% CI, 1.9-2.9 vs OR, 1.2; 95% CI, 0.8-2.0) and both ischemic and hemorrhagic stroke subtypes were associated with mortality (OR, 2.2; 95% CI, 1.8-2.7 vs OR, 1.4; 95% CI, 1.0-1.8). In addition, early and late seizures (OR, 2.4; 95% CI, 1.6-3.4 vs OR, 2.7; 95% CI, 1.8-4.1) and stroke subtypes were associated with poor outcomes (OR, 2.6; 95% CI, 1.9-3.7 vs OR, 1.9; 95% CI, 1.0-3.6).

Conclusions and relevance: Results of this systematic review and meta-analysis suggest that PSSs were associated with significantly increased mortality and severe disability in patients with history of stroke. Unraveling these associations is a high clinical and research priority. Trials of interventions to prevent seizures may be warranted.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Kasner reported receiving grants from Genentech, Bayer, Bristol Myers Squibb, and Diamedica and data safety monitoring board fees from AstraZeneca outside the submitted work. Dr Zaveri reported having a Yale start-up, Alva Health, working on detection of stroke and having patents for a wireless system for epilepsy monitoring and measurement issued, a brain-cooling system, and a system and method for diagnosis and notification regarding the onset of stroke issued outside the submitted work. Dr Hickman reported receiving grants from the National Institutes of Health National Institute of Neurological Disorders and Stroke outside the submitted work. Dr Mazumder reported receiving grants from Fogarty International Center, National Institutes of Health. Dr Yasuda reported receiving lecture fees from UCB and Torrent and advisory board fees from Libbs Farmacêutica outside the submitted work. Dr Ross reported receiving grants from the US Food and Drug Administration, Johnson & Johnson, Medical Devices Innovation Consortium, Agency for Healthcare Research and Quality, the National Institutes of Health/National Heart, Lung, and Blood Institute, and Arnold Ventures and serving as an expert witness for the Greene Law Firm in a qui tam suit alleging violations of the False Claims Act and Anti-Kickback Statute against Biogen Inc that was settled September 2022. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Preferred Reporting Items for Systematic Reviews and Meta-Analyses Flow Diagram
Figure 2.
Figure 2.. Association of Poststroke Seizures With Mortality
The vertical dashed line represents the overall meta-analyzed measure of effect, ie, the pooled odds ratio.
Figure 3.
Figure 3.. Association of Poststroke Seizures With Poor Functional Outcome, Disability, and Dementia
Association of poststroke seizures with poor functional outcome (A), disability (B), and dementia (C).
See this image and copyright information in PMC

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