Does treatment with t-PA increase the risk of developing epilepsy after stroke?

Post-stroke seizures, epilepsy, and mortality in a prospective hospital-based study

Background and objectives

Post-stroke epilepsy (PSE) is a significant concern in the elderly population, with stroke being a leading cause of epilepsy in this demographic. Several factors have shown consistent associations with the risk of developing PSE, including cortical lesions, initial stroke severity, younger age, and the occurrence of early seizures. The primary objectives of this study were two-fold: (1) to determine the incidence of PSE and (2) to identify the risk factors associated with PSE in a prospective cohort of post-stroke patients.

Methods

A prospective single-hospital study was conducted, involving patients diagnosed with acute ischemic and hemorrhagic stroke. The patients were followed up for 2 years (or until death) from the time of admission. Data about seizure occurrence and recurrent stroke were collected. Kaplan-Meyer curves were used for the assessment of PSE incidence and mortality. Possible predictors of PSE and mortality were selected from between-group analysis and tested in multivariable regressions.

Results

Our study enrolled a total of 424 patients diagnosed with acute stroke. Among them, 97 cases (23%) experienced early post-stroke seizures, and 28 patients (6.6%) developed PSE. The cumulative risks of developing PSE were found to be 15.4% after hemorrhagic stroke and 8.7% after ischemic stroke. In multivariable fine and gray regression with competitive risk of death, significant predictors for developing PSE in the ischemic cohort were watershed infarction (HR 6.01, 95% CI 2.29-15.77, p < 0.001) and low Barthel index at discharge (HR 0.98, CI 0.96-0.99, p = 0.04). Furthermore, patients who eventually developed PSE showed slower recovery and presented a worse neurologic status at the time of discharge. The in-hospital dynamics of the National Institutes of Health Stroke Scale (NIHSS) were significantly worse in the PSE group compared to the non-PSE group (p = 0.01).

Discussion

A higher proportion of cases experienced early seizures compared to what has been commonly reported in similar studies. Watershed stroke and low Barthel index at discharge were both identified as independent risk factors of PSE in ischemic strokes, which sheds light on the underlying mechanisms that may predispose individuals to post-stroke epilepsy after experiencing an ischemic stroke.

Incidence and risk factors of post-stroke seizures and epilepsy: systematic review and meta-analysis

OBJECTIVE

Due to variability in reports, the aim of this meta-analysis was to evaluate the incidence and risk factors of post-stroke early seizures (ES) and post-stroke epilepsy (PSE).

METHODS

The MEDLINE, EMBASE and Web of Science databases were searched for post-stroke ES/PSE articles published on any date up to November 2020. Post-stroke ES included seizures occurring within 7 days of stroke, and PSE included at least one unprovoked seizure. Using random effects models, the incidence and risk factors of post-stroke ES and PSE were evaluated. The study was retrospectively registered with INPLASY (INPLASY2023100008).

RESULTS

Of 128 included studies in total, the incidence of post-stroke ES was 0.07 (95% confidence interval [CI] 0.05, 0.10) and PSE was 0.10 (95% CI 0.08, 0.13). The rates were higher in children than adults. Risk factors for post-stroke ES included hemorrhagic stroke (odds ratio [OR] 2.14, 95% CI 1.44, 3.18), severe strokes (OR 2.68, 95% CI 1.73, 4.14), cortical involvement (OR 3.09, 95% CI 2.11, 4.51) and hemorrhagic transformation (OR 2.70, 95% CI 1.58, 4.60). Risk factors for PSE included severe strokes (OR 4.92, 95% CI 3.43, 7.06), cortical involvement (OR 3.20, 95% CI 2.13, 4.81), anterior circulation infarcts (OR 3.28, 95% CI 1.34, 8.03), hemorrhagic transformation (OR 2.81, 95% CI 1.25, 6.30) and post-stroke ES (OR 7.24, 95% CI 3.73, 14.06).

CONCLUSION

Understanding the risk factors of post-stroke ES/PSE may identify high-risk individuals who might benefit from prophylactic treatment.

Mapping Lesion-Related Epilepsy to a Human Brain Network

Importance

It remains unclear why lesions in some locations cause epilepsy while others do not. Identifying the brain regions or networks associated with epilepsy by mapping these lesions could inform prognosis and guide interventions.

Objective

To assess whether lesion locations associated with epilepsy map to specific brain regions and networks.

Design, Setting, and Participants

This case-control study used lesion location and lesion network mapping to identify the brain regions and networks associated with epilepsy in a discovery data set of patients with poststroke epilepsy and control patients with stroke. Patients with stroke lesions and epilepsy (n = 76) or no epilepsy (n = 625) were included. Generalizability to other lesion types was assessed using 4 independent cohorts as validation data sets. The total numbers of patients across all datasets (both discovery and validation datasets) were 347 with epilepsy and 1126 without. Therapeutic relevance was assessed using deep brain stimulation sites that improve seizure control. Data were analyzed from September 2018 through December 2022. All shared patient data were analyzed and included; no patients were excluded.

Main Outcomes and Measures

Epilepsy or no epilepsy.

Results

Lesion locations from 76 patients with poststroke epilepsy (39 [51%] male; mean [SD] age, 61.0 [14.6] years; mean [SD] follow-up, 6.7 [2.0] years) and 625 control patients with stroke (366 [59%] male; mean [SD] age, 62.0 [14.1] years; follow-up range, 3-12 months) were included in the discovery data set. Lesions associated with epilepsy occurred in multiple heterogenous locations spanning different lobes and vascular territories. However, these same lesion locations were part of a specific brain network defined by functional connectivity to the basal ganglia and cerebellum. Findings were validated in 4 independent cohorts including 772 patients with brain lesions (271 [35%] with epilepsy; 515 [67%] male; median [IQR] age, 60 [50-70] years; follow-up range, 3-35 years). Lesion connectivity to this brain network was associated with increased risk of epilepsy after stroke (odds ratio [OR], 2.82; 95% CI, 2.02-4.10; P < .001) and across different lesion types (OR, 2.85; 95% CI, 2.23-3.69; P < .001). Deep brain stimulation site connectivity to this same network was associated with improved seizure control (r, 0.63; P < .001) in 30 patients with drug-resistant epilepsy (21 [70%] male; median [IQR] age, 39 [32-46] years; median [IQR] follow-up, 24 [16-30] months).

Conclusions and Relevance

The findings in this study indicate that lesion-related epilepsy mapped to a human brain network, which could help identify patients at risk of epilepsy after a brain lesion and guide brain stimulation therapies.

Risk of poststroke epilepsy after reperfusion therapies: A national cohort study

BACKGROUND AND PURPOSE

The risk of poststroke epilepsy (PSE) after endovascular treatment (EVT) is not well characterized. In this nationwide study, we assessed the risk of PSE after EVT and identified associated predictors.

METHODS

We included all individuals (n = 3319) treated with EVT (±intravenous thrombolysis [IVT]) between 2015 and 2019 in the Swedish National Quality Register for EVT. Two control groups were identified from the Swedish Stroke Register: the first treated with IVT alone (n = 3132) and the second with no treatment (n = 3184), both matched for age, sex, stroke severity, and time of stroke.

RESULTS

PSE developed in 7.9% (n = 410). The survival-adjusted 2-year risk was 6.5% (95% confidence interval [CI] = 5.28-7.70) after EVT, 10.0% (95% CI = 8.25-11.75) after IVT, and 12.3% after no revascularization (95% CI = 10.33-14.25). The hazard ratio (HR) of PSE after EVT was almost half compared to no treatment (HR = 0.51, 95% CI = 0.41-0.64). The risk of PSE after EVT was lower compared to no treatment in a multivariable Cox model that adjusted for age, sex, hemicraniectomy, and stroke severity (HR = 0.76, 95% CI = 0.60-0.96). Multivariable predictors of PSE after EVT were large infarction on computed tomography Day 1, high posttreatment National Institutes of Health Stroke Scale score, and need of assistance 3 months after stroke. IVT before EVT was associated with a lower risk of PSE (HR = 0.66, 95% CI = 0.46-0.94).

CONCLUSIONS

This nationwide study identified a reduced risk of PSE after EVT. Markers of severe infarction after EVT were associated with PSE, whereas IVT given before EVT was protective.

Asymmetric distribution of enlarged perivascular spaces in centrum semiovale may be associated with epilepsy after acute ischemic stroke

Objective

To investigate the factors influencing enlarged perivascular space (EPVS) characteristics at the onset of acute ischemic stroke (AIS), and whether the PVS characteristics can predict later post‐stroke epilepsy (PSE).

Methods

A total of 312 patients with AIS were identified, of whom 58/312 (18.6%) developed PSE. Twenty healthy participants were included as the control group. The number of PVS in the basal ganglia (BG), centrum semiovale (CS), and midbrain (MB) was manually calculated on T₂‐weighted MRI. The scores and asymmetry index (AI) of EPVS in each region were compared among the enrolled participants. Other potential risk factors for PSE were also analyzed, including NIHSS at admission and stroke etiologies.

Results

The EPVS scores were significantly higher in the bilateral BG and CS of AIS patients compared to those of the control group (both p < 0.01). No statistical differences in EPVS scores in BG, CS, and MB were obtained between the PSE group and the nonepilepsy AIS group (all p > 0.01). However, markedly different AI scores in CS were found between the PSE group and the nonepilepsy AIS group (p = 0.004). Multivariable analysis showed that high asymmetry index of EPVS (AI≥0.2) in CS was an independent predictor for PSE (OR = 3.7, 95% confidence interval 1.5–9.1, p = 0.004).

Conclusions

Asymmetric distribution of EPVS in CS may be an independent risk factor and a novel imaging biomarker for the development of PSE. Further studies to understand the mechanisms of this association and confirmation with larger patient populations are warranted.

Hospital Revisits for Post-Ischemic Stroke Epilepsy after Acute Stroke Interventions

OBJECTIVES

Improvements in acute stroke care have led to an increase in ischemic stroke survivors, who are at risk for development of post-ischemic stroke epilepsy (PISE). The impact of therapies such as thrombectomy and thrombolysis on risk of hospital revisits for PISE is unclear. We utilized administrative data to investigate the association between stroke treatment and PISE-related visits.

MATERIALS AND METHODS

Using claims data from California, New York, and Florida, we performed a retrospective analysis of adult survivors of acute ischemic strokes. Patients with history of epilepsy, trauma, infections, or tumors were excluded. Included patients were followed for a primary outcome of revisits for seizures or epilepsy. Cox proportional hazards regression was used to identify covariates associated with PISE.

RESULTS

In 595,545 included patients (median age 74 [IQR 21], 52% female), the 6-year cumulative rate of PISE-related revisit was 2.20% (95% CI 2.16-2.24). In multivariable models adjusting for demographics, comorbidities, and indicators of stroke severity, IV-tPA (HR 1.42, 95% CI 1.31-1.54, p<0.001) but not MT (HR 1.62, 95% CI 0.90-1.50, p=0.2) was associated with PISE-related revisit. Patients who underwent decompressive craniectomy experienced a 2-fold increase in odds for returning with PISE (HR 2.35, 95% CI 1.69-3.26, p<0.001). In-hospital seizures (HR 4.06, 95% CI 3.76-4.39, p<0.001) also elevated risk for PISE.

SIGNIFICANCE

We demonstrate that ischemic stroke survivors who received IV-tPA, underwent decompressive craniectomy, or experienced acute seizures were at increased risk PISE-related revisit. Close attention should be paid to these patients with increased potential for long-term development of and re-hospitalization for PISE.

Seizures and epilepsy in patients with ischaemic stroke

BACKGROUND

With the increased efficacy of stroke treatments, diagnosis and specific treatment needs of patients with post-stroke seizures (PSS) and post-stroke epilepsy have become increasingly important. PSS can complicate the diagnosis of a stroke and the treatment of stroke patients, and can worsen post-stroke morbidity. This narrative review considers current treatment guidelines, the specifics of antiseizure treatment in stroke patients as well as the state-of-the-art in clinical and imaging research of post-stroke epilepsy. Treatment of PSS needs to consider indications for antiseizure medication treatment as well as individual clinical and social factors. Furthermore, potential interactions between stroke and antiseizure treatments must be carefully considered. The relationship between acute recanalizing stroke therapy (intravenous thrombolysis and mechanical thrombectomy) and the emergence of PSS is currently the subject of an intensive discussion. In the subacute and chronic post-stroke phases, important specific interactions between necessary antiseizure and stroke treatments (anticoagulation, cardiac medication) need to be considered. Among all forms of prevention, primary prevention is currently the most intensively researched. This includes specifically the repurposing of drugs that were not originally developed for antiseizure properties, such as statins. PSS are presently the subject of extensive basic clinical research. Of specific interest are the role of post-stroke excitotoxicity and blood-brain barrier disruption for the emergence of PSS in the acute symptomatic as well as late (> 1 week after the stroke) periods. Current magnetic resonance imaging research focussing on glutamate excitotoxicity as well as diffusion-based estimation of blood-brain barrier integrity aim to elucidate the pathophysiology of seizures after stroke and the principles of epileptogenesis in structural epilepsy in general. These approaches may also reveal new imaging-based biomarkers for prediction of PSS and post-stroke epilepsy.

CONCLUSION

PSS require the performance of individual risk assessments, accounting for the potential effectiveness and side effects of antiseizure therapy. The use of intravenous thrombolysis and mechanical thrombectomy is not associated with an increased risk of PSS. Advances in stroke imaging may reveal biomarkers for PSS.

Impact of drug treatment and drug interactions in post-stroke epilepsy

Stroke is a huge burden on our society and this is expected to grow in the future due to the aging population and the associated co-morbidities. The improvement of acute stroke care has increased the survival rate of stroke patients, and many patients are left with permanent disability, which makes stroke the main cause of adult disability. Unfortunately, many patients face other severe complications such as post-stroke seizures and epilepsy. Acute seizures (ASS) occur within 1 week after the stroke while later occurring unprovoked seizures are diagnosed as post-stroke epilepsy (PSE). Both are associated with a poor prognosis of a functional recovery. The underlying neurobiological mechanisms are complex and poorly understood. There are no universal guidelines on the management of PSE. There is increasing evidence for several risk factors for ASS/PSE, however, the impacts of recanalization, drugs used for secondary prevention of stroke, treatment of stroke co-morbidities and antiseizure medication are currently poorly understood. This review focuses on the common medications that stroke patients are prescribed and potential drug interactions possibly complicating the management of ASS/PSE.

Multifactorial Predictors of Late Epileptic Seizures Related to Stroke: Evaluation of the Current Possibilities of Stratification Based on Existing Prognostic Models-A Comprehensive Review

Background: Epilepsy associated with strokes is a significant clinical and public health problem and has a negative impact on prognosis and clinical outcome. A late epileptic seizure occurring seven days after stroke is actually equated with poststroke epilepsy due to the high risk of recurrence. Predictive models evaluated in the acute phase of stroke would allow for the stratification and early selection of patients at higher risk of developing late seizures. Methods: The most relevant papers in this field were reviewed to establish multifactorial predictors of late seizures and attempt to standardize and unify them into a common prognostic model. Results: Clinical and radiological factors have become the most valuable and reproducible predictors in many reports, while data on electroencephalographic, genetic, and blood biomarkers were limited. The existing prognostic models, CAVE and SeLECT, based on relevant, readily available, and routinely assessed predictors, should be validated and improved in multicenter studies for widespread use in stroke units. Conclusions: Due to contradictory reports, a common and reliable model covering all factors is currently not available. Further research might refine forecasting models by incorporating advanced radiological neuroimaging or quantitative electroencephalographic analysis.

Intravenous thrombolysis or mechanical thrombectomy do not increase risk of acute symptomatic seizures in patients with ischemic stroke

Recent data have suggested that performing recanalizing therapies in ischemic stroke might lead to an increased risk of acute symptomatic seizures. This applies to both intravenous thrombolysis and mechanical thrombectomy. We therefore determined the frequency of acute symptomatic seizures attributable to these two recanalization therapies using a large, population-based stroke registry in Central Europe. We performed two matched 1:1 case–control analyses. In both analyses, patients were matched for age, stroke severity on admission and pre-stroke functional status. The first analysis compared patients treated with intravenous thrombolysis to a non-recanalization control group. To isolate the effect of mechanical thrombectomy, we compared patients with both mechanical thrombectomy and intravenous thrombolysis to those with only intravenous thrombolysis treatment in a second analysis. From 135,117 patients in the database, 13,356 patients treated with only intravenous thrombolysis, and 1013 patients treated with both intravenous thrombolysis and mechanical thrombectomy were each matched to an equivalent number of controls. Patients with intravenous thrombolysis did not suffer from clinically apparent acute symptomatic seizures significantly more often than non-recanalized patients (treatment = 199; 1.5% vs. control = 237; 1.8%, p = 0.07). Mechanical thrombectomy in addition to intravenous thrombolysis also was not associated with an increased risk of acute symptomatic seizures, as the same number of patients suffered from seizures in the treatment and control group (both n = 17; 1.7%, p = 1). In a large population-based stroke registry, the frequency of clinically apparent acute symptomatic seizures was not increased in patients who received either intravenous thrombolysis alone or in conjunction with mechanical thrombectomy.

Incidence and Association of Reperfusion Therapies With Poststroke Seizures: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

We performed a systematic review and meta-analysis to assess the incidence and risk of seizures following acute stroke reperfusion therapy (intravenous thrombolysis [IVT] with r-tPA [recombinant tissue-type plasminogen activator], mechanical thrombectomy or both).

METHODS

We searched major databases (MEDLINE, SCOPUS, and Cochrane Library) for articles published between 1995 and October 28, 2019. The primary outcome was the overall and treatment specific pooled incidence of poststroke seizures (PSS) following acute reperfusion therapy. We also computed the pooled incidence of early poststroke seizures and late poststroke seizures separately for all studies. We derived the risk of PSS associated with IVT in the pooled cohort of patients who received only IVT. The small number of studies (<3) that reported on the risk of PSS associated with mechanical thrombectomy alone or in combination with IVT did not allow us to compute an estimate of the risk of seizures associated with this therapy.

RESULTS

We identified 13 753 patients with stroke, of which 592 had seizures. The pooled incidence of PSS was 5.9 % (95% CI, 4.2%-8.2%). PSS incidence rates among patients with stroke treated with IVT, mechanical thrombectomy, and both were respectively 6.1% (95% CI, 3.6%-10.2%), 5.9% (95% CI, 4.1%-8.4%), and 5.8 % (95% CI, 3.0%-10.9%). The incidence of late PSS was 6.7% (95% CI, 4.01%-11.02%) and that of early PSS was 3.14% (95% CI, 2.05%-4.76%). The pooled odds ratio for the association between IVT and PSS was 1.24 (95% CI, 0.75-2.05).

CONCLUSIONS

The findings of this meta-analysis suggest that about one in 15 ischemic stroke patients treated with IVT, mechanical thrombectomy, or both develop seizures independently of the specific reperfusion treatment that they received.

Circulating mRNA and microRNA profiling analysis in patients with ischemic stroke

To provide insight into molecular diagnosis and individualized treatment of ischemic stroke (IS), several available datasets in IS were analyzed to identify the differentially expressed genes and microRNAs (miRNAs). Series matrix files from GSE22255 and GSE16561 (mRNA profiles), a well as GSE110993 (miRNA profile) were downloaded from the Gene Expression Omnibus database. System-level clustering was performed with GeneCluster 3.0 software, and gene annotation and pathway enrichment were performed with gene ontology analysis and Database for Annotation, Visualization and Integrated Discovery software. For a protein-protein interaction (PPI) network, Biological General Repository for Interaction Datasets and IntAct interaction information were integrated to determine the interaction of differentially expressed genes. The selected miRNA candidates were imported into the TargetScan, miRDB and miRecords databases for the prediction of target genes. The present study identified 128 upregulated and 231 downregulated genes in female stroke patients, and 604 upregulated and 337 downregulated genes in male stroke patients compared with sex- and age-matched controls. The construction of a PPI network demonstrated that male stroke patients exhibited YWHAE, CUL3 and JUN as network center nodes, and in female patients CYLD, FOS and PIK3R1 interactions were the strongest. Notably, these interactions are mainly involved in immune inflammatory response, apoptosis and other biological pathways, such as blood coagulation. Female and male upregulated genes were cross-validated with another set of Illumina HumanRef-8 v3.0 expression beadchip (GSE16561). Functional item association networks, gene function networks and transcriptional regulatory networks were successfully constructed, and the relationships between miRNAs and target genes were successfully predicted. The present study identified a number of transcription factors, including DEFA1, PDK4, SDPR, TCN1 and MMP9, and miRNAs, including miRNA (miR)-21, miR-143/145, miR-125-5p and miR-122, which may serve important roles in the development of cerebral stroke and may be important molecular indicators for the treatment of IS.

Reperfusion therapies and poststroke seizures

Seizures are not only a frequent complication of stroke but have been associated with an unfavorable functional and vital outcome of patients who have had stroke. Facing a new paradigm of acute standard stroke care, acute symptomatic seizures in this clinical setting deserve to be rethought. Reperfusion therapies, the gold standard treatment for acute ischemic stroke, improve long-term survival and outcome of patients who have had stroke and have been associated both with clinical seizures and the occurrence of epileptiform activity in the electroencephalogram (EEG). This narrative review describes the different physiopathological mechanisms underlying the possible association between reperfusion therapies and seizures, both acute symptomatic seizures and unprovoked seizures, and the current evidence regarding the risk of poststroke seizures in treated patients. It also identifies the gaps in our knowledge to foster future studies in this field. By different mechanisms, reperfusions therapies may have opposing effects on the risk of poststroke seizures. There is a need for a better definition of the specific physiopathology of seizures in clinical practice, as many factors can be recognized. Additionally, most of the current clinical evidence refers to acute symptomatic seizures and not to unprovoked seizures or poststroke epilepsy, and our analysis does not support the existence of a strong association between thrombolysis and poststroke seizures. So far, the impact of reperfusion therapies on the frequency of poststroke seizures is unclear. To study this effect, many clinical challenges must be overcome, including a better and clear operational definition of seizures and stroke characteristics, the standard of stroke and epilepsy care and EEG monitoring, and the degree of reperfusion success. Prospective, high quality, larger, and longer follow-up multicentric studies are urgently needed. Additionally, stroke registries can also prove useful in better elucidate whether there is an association between reperfusion therapies and seizures. This article is part of the Special Issue "Seizures & Stroke".

Incidence of early poststroke seizures during reperfusion therapies in patients with acute ischemic stroke: An observational prospective study: (TESI study: "Trombolisi/Trombectomia e crisi Epilettiche precoci nello Stroke Ischemico")

INTRODUCTION

The aim of this study was to prospectively investigate the occurrence of early poststroke seizures (within 7 days of stroke) in patients undergoing reperfusion therapies (intravenous rtPA [recombinant tissue plasminogen activator] and/or endovascular thrombectomy) in comparison to those not undergoing these procedures.

METHODS

Patients aged ≥18 years with acute ischemic stroke admitted in five Italian centers were prospectively recruited. Clinical data, details on stroke type and etiology, stroke treatment, and radiological data were collected. The frequency of early poststroke seizures was assessed, and predictive factors for their occurrence were evaluated.

RESULTS

Five hundred and sixteen patients (262 in the reperfusion therapies group) were included. Stroke severity on admission and at discharge was higher among patients undergoing reperfusion therapies. Ten patients (3.8%) undergoing reperfusion therapies and 6 (2.3%) of those not receiving these treatments experienced early poststroke seizures (p = 0.45). There were no differences in any of the baseline characteristics between patients experiencing and those not experiencing early seizures.

CONCLUSION

The incidence of early poststroke seizures was overall rare, and no significant differences emerged between patients receiving and those not receiving reperfusion therapies. This article is part of the Special Issue "Seizures and Stroke".

Younger age at stroke onset but not thrombolytic treatment predicts poststroke epilepsy: An updated meta-analysis

AIMS

Stroke is the most commonly identified cause of late-onset epilepsy. Risk factors for poststroke epilepsy (PSE) are partially elucidated, and many studies have been performed in recent years. We aimed to update our previous systematic review and meta-analysis on risk factors for PSE.

METHODS

PubMed, Google Scholar, and Scopus databases were searched. Articles published in English (1987-2019) were included. Odds ratios (OR) and mean values were calculated for examined variables.

RESULTS

Thirty studies with different designs were included, enrolling 26,045 patients who experienced stroke, of whom 1800 had PSE, corresponding to a prevalence of 7%. Cortical lesions (OR: 3.58, 95% confidence interval (CI): 2.35-5.46, p < 0.001), hemorrhagic component (OR: 2.47, 95% CI: 1.68-3.64, p < 0.001), early seizures (ES) (OR: 4.88, 95% CI: 3.08-7.72, p < 0.001), and younger age at stroke onset (difference in means: 2.97 years, 95% CI: 0.78 to 5.16, p = 0.008) favor PSE. Sex and acute treatment with recombinant tissue plasminogen activator (rtPA) do not predict the occurrence of PSE.

CONCLUSION

Despite limitations due to the uneven quality and design of the studies, the present meta-analysis confirms that cortical involvement, hemorrhagic component, and ES are associated with a higher risk of PSE. In this update, younger age at stroke onset but not thrombolytic treatment seems to increase the risk for PSE. This article is part of the Special Issue "Seizures & Stroke".

Risk Factors for Epilepsy After Thrombolysis for Ischemic Stroke: A Cohort Study

The effects of thrombolysis in seizure and epilepsy after acute ischemic stroke have been poorly explored. In this study, we examine risk factors and consequences of intravenous rt-PA for treatment of acute ischemic stroke. In a retrospective cohort study we evaluate risk factors for seizure and epilepsy after stroke thrombolysis, as well as the impact of seizures and epilepsy in outcome of stroke patients. In our cohort, mean age of patients was 67.2 years old (SD = 13.1) and 79 of them (51.6%) were male and. Initial NIHSS mean score were 10.95 (SD = 6.25). Three months NIHSS mean score was 2.09 (SD = 3.55). Eighty seven (56.9%) patients were mRS of 0–1 after thrombolysis. Hemorrhagic transformation was observed in 22 (14.4%) patients. Twenty-one (13.7%) patients had seizures and 15 (9.8%) patients developed epilepsy after thrombolysis. Seizures were independently associated with hemorrhagic transformation (OR = 3.26; 95% CI = 1.08–9.78; p = 0.035) and with mRS ≥ 2 at 3 months after stroke (OR = 3.51; 95% CI = 1.20–10.32; p = 0.022). Hemorrhagic transformation (OR = 3.55; 95% CI = 1.11–11.34; p = 0.033) and mRS ≥ 2 at 3 months (OR = 5.82; 95% CI = 1.45–23.42; p = 0.013) were variables independently associated with post-stroke epilepsy. In our study, independent risks factors for poor outcome in stroke thrombolysis were age (OR = 1.03; 95% CI = 1.01–1.06; p = 0.011), higher NIHSS (OR = 1.08; 95% CI = 1.03–1.14; p = 0.001), hemorrhagic transformation (OR = 2.33; 95% CI = 1.11–4.76; p = 0.024), seizures (OR = 3.07; 95% CI = 1.22–7.75; p = 0.018) and large cortical area (ASPECTS ≤ 7) (OR = 2.04; 95% CI = 1.04–3.84; p = 0.036). Concluding, in this retrospective cohort study, the neurological impairment after thrombolysis (but not before) and hemorrhagic transformation remained independent risk factors for seizures or post-stroke epilepsy after thrombolysis. Moreover, we observed that seizures emerged as an independent risk factor for poor outcome after thrombolysis therapy in stroke patients (OR = 3.07; 95% CI = 1.22–7.75; p = 0.018).

Incidence, Implications, and Management of Seizures Following Ischemic and Hemorrhagic Stroke

PURPOSE OF REVIEW

In this review, we summarize the recent literature regarding the incidence and treatment of seizures arising after ischemic and hemorrhagic strokes. Additionally, we identify open questions in guidelines and standard clinical care to aid future studies aiming to improve management of seizures in post-stroke patients.

RECENT FINDINGS

Studies demonstrate an increasing prevalence of seizures following strokes, probably a consequence of advances in post-stroke management and expanding use of continuous EEG monitoring. Post-stroke seizures are associated with longer hospitalization and increased mortality; therefore, prevention and timely treatment of seizures are important. The standard of care is to treat recurrent seizures with anti-epileptic drugs (AEDs) regardless of the etiology. However, there are no established guidelines currently for prophylactic use of AEDs following a stroke. The prevalence of post-stroke seizures is increasing. Further studies are needed to determine the risk factors for recurrent seizures and epilepsy after strokes and optimal treatment strategies.

[Epileptic seizures and epilepsy after a stroke : Incidence, prevention and treatment]

Following stroke, 3-6% of patients develop acute symptomatic seizures within the first 7 days. The rate is higher after cerebral haemorrhage compared to ischaemia. In 10-12% of patients, after more than 7 days unprovoked seizures occur. Due to these low incidence rates, primary prophylaxis with antiepileptic drugs is generally not necessary. Following one acute symptomatic seizure, recurrence risk within the first 7 days post-stroke is 10-20%, generally arguing against secondary prophylaxis with an antiepileptic drug. In clinical practice however, antiepileptic drug treatment in this constellation is often initiated. If this is done, the antiepileptic drug should be withdrawn soon after the acute phase, as the long-term risk for manifestation of an unprovoked seizure is approximately 30%. Following one post-stroke unprovoked seizure, recurrence risk within the next 10 years is more than 70%, this defines epilepsy. In this case, antiepileptic drug treatment is regularly recommended.

The role of plasminogen activators in stroke treatment: fibrinolysis and beyond

Although recent technical advances in thrombectomy have revolutionised acute stroke treatment, prevalence of disability and death related to stroke remain high. Therefore, plasminogen activators-eukaryotic, bacterial, or engineered forms that can promote fibrinolysis by converting plasminogen into active plasmin and facilitate clot breakdown-are still commonly used in the acute treatment of ischaemic stroke. Hence, plasminogen activators have become a crucial area for clinical investigation for their ability to recanalise occluded arteries in ischaemic stroke and to accelerate haematoma clearance in haemorrhagic stroke. However, inconsistent results, insufficient evidence of efficacy, or reports of side-effects in trial settings might reduce the use of plasminogen activators in clinical practice. Additionally, the mechanism of action for plasminogen activators could extend beyond the vessel lumen and involve plasminogen-independent processes, which would suggest that plasminogen activators have also non-fibrinolytic roles. Understanding the complex mechanisms of action of plasminogen activators can guide future directions for therapeutic interventions in patients with stroke.

Epilepsy after stroke: Definitions, problems and a practical approach for clinicians

Stroke, whether ischemic or hemorrhagic, is the main etiology of epilepsy in the elderly. However, incidences and outcomes differ according to stroke subtype and delay of onset following the stroke. While the medical literature is extensive, it is not always consistent, and many questions still remain regarding risk factors and management of vascular epilepsy. Thus, the present report here is an overview of the clinical aspects of vascular epilepsy using a practical approach that integrates data from meta-analyses and the more recently published expert recommendations.

Stroke-related epilepsy

Stroke is the cause of about 10% of all epilepsy and 55% of newly diagnosed seizures among the elderly. Although recent advances in acute stroke therapy have improved longevity, there has been a consequent rise in the prevalence of stroke-related epilepsy (STRE). Many clinical studies make a distinction between early (within 7 days of onset of stroke) and late (beyond 7 days of onset of stroke) seizures based on presumed pathophysiological differences. Although early seizures are thought to be the consequence of local metabolic disturbances without altered neuronal networks, late seizures are thought to occur when the brain has acquired a predisposition for seizures. Overall, STRE has a good prognosis, being well controlled by antiepileptic drugs. However, up to 25% of cases become drug resistant. STRE can also result in increased morbidity, longer hospitalization, greater disability at discharge and greater resource utilization. Additional controlled trials are needed to explore the primary and secondary prevention of STRE as well as to provide high-quality evidence on efficacy and tolerability of antiepileptic drugs to guide treatment of STRE. Robust pre-clinical and clinical prediction models of STRE are also needed to develop treatments to prevent the transformation of infarcted tissue into an epileptic focus.

Estimation of seizures prevalence in ischemic strokes after thrombolytic therapy

PURPOSE

Post stroke seizures are a complication that occur in 5-20% of acute ischemic stroke (AIS) patients, cause a reduction in quality of life and a greater burden on the health system. There is not enough data regarding an association between today's standard of care treatment in AIS: recombinant tissue plasminogen activator (r-tPA) and the risk for post stroke seizures. Our aim in this work is to reveal such a connection.

METHOD

A non-randomized retrospective cohort-controlled study of 234 patients, who were hospitalized with acute ischemic stroke at Kaplan Medical Center in the years 2009-2015 and were divided into two different treatment groups: r-tPA and antiaggregant therapy(n = 141) and antiaggregant therapy only (n = 95) was conducted by us. Information regarding demographics, medical history, nature of the event, including NIHSS values on admission, discharge, and post stroke seizures, were obtained for each group. Follow-up was done for one year.

RESULTS

During the year of follow-up, 19 patients (8.1%) of the overall cohort, developed seizures: 12 of them (12.6%) belonged to the control group and 7 (5%) to the study group p < 0.05). Results showed a decrease in the risk for developing seizure when treated with r-tpA, comparing to antiaggregants (odds ratio = 0.64).

CONCLUSION

This study suggests there is an association between r-tPA treatment and reduction of the risk for post stroke seizures.

The efficacy of gastrodin in combination with folate and vitamin B12 on patients with epilepsy after stroke and its effect on HMGB-1, IL-2 and IL-6 serum levels

This study evaluated the efficacy of gastrodin in combination with folate (FOL) and vitamin-B12 (V-B12) on patients with epilepsy after stroke (EAS) and its effect on high-mobility group protein B1 (HMGB-1), interleukin-1 (IL-1), and IL-6 serum levels. The clinical data of 92 EAS patients admitted for treatment between April, 2014 and March, 2016 were collected. These patients were randomly divided into control and observation groups (n=46 each) using computer software. Patients in the control group were administered only regular antiepileptic drugs, whereas observation group patients also received a combination of gastrodin, FOL and V-B12. After treatment, we compared efficacy, frequency of epileptic seizure, and Montreal cognitive assessment (MoCA) scores. Serum homocysteine (HCY), FOL and V-B12 levels were detected 3 months later. Enzyme-linked immunosorbent assay (ELISA) was used to detect changes in serum HMGB-1, IL-2 and IL-6 levels at one day before treatment and on the 7th, 21st, 30th and 90th days after treatment. Pearson's correlation coefficient was utilized to analyze the correlations of HMGB-1 with IL-2 and IL-6. The total treatment effectiveness rate was 95.65% in the observation group, which was significantly higher than the control group (73.91%, p<0.05). Epileptic seizure frequency and MoCA scores significantly improved in the observation group (p<0.05). Serum HCY levels were significantly lower, whereas FOL and V-B12 serum levels were significantly higher, at 3 months post-treatment start in the observation group relative to control group (p<0.05). After treatment, serum HMGB-1, IL-2 and IL-6 levels progressively decreased over time in both groups, but observation group levels were significantly lower than in control group (p<0.05). Pearson's correlation coefficient analysis showed that HMGB-1 levels were positively correlated with IL-2 and IL-6 levels. A combination of gastrodin, FOL and V-B12 for EAS can significantly improve inflammatory response symptoms, decrease HCY levels, and increase FOL and V-B12 levels in serum while effectively controlling epileptic seizures, thus exhibiting relatively better clinical efficacy. Therefore, this combination treatment is worthy of being promoted in clinical practice.

Incidence of seizure in stroke patients treated with recombinant tissue plasminogen activator: A systematic review and meta-analysis

Background

Recombinant tissue plasminogen activator is the only FDA-approved thrombolytic agent for acute stroke treatment. However, there are concerns that recombinant tissue plasminogen activator may increase the risk of seizures (including early and late seizures).

Aims

We performed a systematic review to assess the incidence of seizures and the association of recombinant tissue plasminogen activator with seizure occurrence.

Summary of review

We searched major databases for articles published between 1995 and February 2016. The pooled incidence of post-stroke seizure, early seizure, late seizure, and seizures sub-types was estimated overall and by status for recombinant tissue plasminogen activator treatment, and unadjusted odds ratio used to quantify the effects of recombinant tissue plasminogen activator on post-stroke seizure occurrence. In all, 4362 stroke participants were included with 49–63% being male and median age ranging from 68 to 71 years. A total of 792 received recombinant tissue plasminogen activator. The incidence of post-stroke seizure per 1000 participants (95% CI) was 95 (31–196) overall, 113 (49–202) in recombinant tissue plasminogen activator and 169 (6–326) in non-recombinant tissue plasminogen activator-treated (all heterogeneity- p<0.0001). Incidence of early seizure per 1000 (95% CI) was 35 (27–45) overall; 34 (22–50) among recombinant tissue plasminogen activator-treated patients, and 36 (25–48) among recombinant tissue plasminogen activator naïve participants (all heterogeneity- p > 0.826). The pool incidence rate per 1000 (95% CI) of late seizure was 84 (4–263), 46 (2–145), and 212 (184–241), respectively, in the overall, the recombinant tissue plasminogen activator-treated group and non-recombinant tissue plasminogen activator-treated group (heterogeneity for overall and recombinant tissue plasminogen activator-treated group < 0.0001, non-recombinant tissue plasminogen activator naïve = 0.999). The pooled odds ratio for post-stroke seizure (recombinant tissue plasminogen activator vs. no recombinant tissue plasminogen activator) was 0.94 (95% CI: 0. 17–5.26, heterogeneity- p < 0.0001). The pooled incidence per 1000 participants (95% CI) was 30 (0–144), 17 (2–49), 16 (2–44), and 9 (0–50), respectively, for focal seizure without impairment of consciousness, focal seizure with impairment of consciousness, generalized convulsive seizure, and status epilepticus; all heterogeneity- p < 0.0003. Accompanying pooled odds ratio (recombinant tissue plasminogen activator vs. no recombinant tissue plasminogen activator) based on one study was always in favor of non-significantly lower risk in recombinant tissue plasminogen activator-treated patients (all heterogeneity- p = 1). There were insufficient data to compute pooled odds ratio for early and late seizure.

Conclusions

Seizures affect nearly 1 out of every 10 stroke patients with inconclusive suggestion that rates are similar in recombinant tissue plasminogen activator-treated and recombinant tissue plasminogen activator naïve patients. Large prospective studies are needed to better understand the relationship between recombinant tissue plasminogen activator and post-stroke seizure occurrence.

European Stroke Organisation guidelines for the management of post-stroke seizures and epilepsy

Background

Following stroke, acute symptomatic seizures (manifestation within seven days) and epilepsy, i.e. occurrence of at least one unprovoked seizure (manifestation after more than seven days), are reported in 3-6% and up to 12% of patients, respectively. Incidence of acute symptomatic seizures is higher in intracranial haemorrhage (10-16%) than in ischaemic stroke (2-4%). Acute symptomatic seizures and unprovoked seizure may be associated with unfavourable functional outcome and increased mortality. In view of the clinical relevance, the European Stroke Organisation has issued evidence-based guidelines on the management of post-stroke seizures and epilepsy.

Method

A writing committee of six clinicians and researchers from five European countries and Israel identified seven questions relating to prevention of (further) post-stroke seizures and epilepsy and to amelioration of functional outcome and prevention of mortality. Recommendations are based on findings in randomised controlled trials and observational studies using the grading of recommendations assessment, development and evaluation approach.

Results

In the absence of adequately powered randomised controlled trials, evidence for all recommendations is very low. Based on findings in observational studies, some weak recommendations have been made. In most instances, we suggest not to administer antiepileptic drugs. Due to high incidence of seizure recurrence after one post-stroke unprovoked seizure, secondary antiepileptic drugs prophylaxis needs to be considered.

Conclusion

Due to very low evidence, these guidelines only give some weak recommendations on prevention of occurrence and recurrence of post-stroke acute symptomatic seizures and unprovoked seizure. Adequately powered randomised controlled trials are required to assess interventions for post-stroke seizure management.

Epilepsy in cerebrovascular diseases: Review of experimental and clinical data with meta-analysis of risk factors

OBJECTIVE

Seizures may occur in close temporal association with a stroke or after a variable interval. Moreover, epilepsy is often encountered in patients with leukoaraiosis. Although early post-stroke seizures have been studied extensively, less attention has been paid to post-stroke epilepsy (PSE) and to epilepsy associated with leukoaraiosis (EAL). The aim of this paper is to review data concerning pathophysiology, prognosis, and treatment of PSE and EAL.

METHODS

We performed an extensive literature search to identify experimental and clinical articles on PSE and EAL. We also conducted a systematic review of risk factors for PSE and EAL among eligible studies.

RESULTS

PSE is caused by enhanced neuronal excitability within and near the scar. The role played by white matter changes in EAL remains to be elucidated. Meta-analysis showed that cortical involvement (odds ratio [OR] 3.71, 95% confidence interval [CI] 2.34-5.90, p < 0.001), cerebral hemorrhage (OR 2.41, 95% CI 1.57-3.70, p < 0.001), and early seizures (OR 4.43, 95% CI 2.36-8.32, p < 0.001) are associated with an increased risk of PSE. As regards EAL, no prospective, population-based studies evaluated the role of different variables on seizure risk. Studies about the management of PSE are limited. PSE is generally well controlled by drugs. Data about risk factors, prognosis, and treatment of EAL are lacking.

SIGNIFICANCE

Pathophysiology and risk factors are well defined for PSE but need to be elucidated for EAL. Management of PSE and EAL relies on the clinician's judgment and should be tailored on an individual basis.