Incidence, predictors, and outcome of early seizures after mechanical thrombectomy

The Primary Prevention of Poststroke Epilepsy in Patients With Middle Cerebral Artery Infarct: Protocol for a Randomized Controlled Trial

BACKGROUND

Poststroke epilepsy poses a significant clinical challenge for individuals recovering from strokes, leading to a less favorable long-term outlook and increased mortality rates. Existing studies have primarily concentrated on administering antiseizure or anticonvulsant treatments only after the onset of late-onset seizures, without intervening during the epileptogenesis phase following a stroke.

OBJECTIVE

This research protocol is designed to conduct a randomized controlled trial to assess whether the early, preventive introduction of low-dose antiepileptic drug therapy (levetiracetam [LEV] or perampanel [PER]) in patients who have experienced middle cerebral artery (MCA) infarction can reduce the risk of developing poststroke epilepsy (primary prevention).

METHODS

Participants with MCA infarction, either with or without reperfusion treatments, will be recruited and promptly receive preventive intervention within 72 hours of the stroke occurrence. These participants will be randomly assigned to receive either PER (4 mg per day), LEV (1000 mg per day), or a placebo that matches the active drugs. This treatment will continue for 12 weeks after allocation. Brain magnetic resonance imaging will be used to confirm the presence of MCA territory infarction, and an electroencephalography will be used to ensure the absence of epileptiform discharges or electrographic seizures at the time of the stroke. All participants will undergo follow-up assessments for 72 weeks after allocation.

RESULTS

The primary outcome under evaluation will be the incidence of poststroke epilepsy in the 3 groups following the 18-month study period. Secondary outcomes will encompass the time to the occurrence of the first seizure, the severity of seizures, any treatment-related adverse events, and the modified Rankin scale score at 3 and 18 months. Exploratory outcomes will involve comparing the effectiveness and safety of PER and LEV.

CONCLUSIONS

We anticipate that the intervention groups will experience a lower incidence and reduced severity of poststroke epilepsy compared to the control group after 18 months. We aim to establish evidence supporting the potential preventive effects of LEV and PER on poststroke seizures and epilepsy in patients with MCA infarction, as well as to explore the antiepileptogenic potential of both LEV and PER in patients with major ischemic strokes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04858841; https://clinicaltrials.gov/study/NCT04858841.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49412.

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

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.

Risk assessment of mechanic thrombectomy on post-stroke seizures: a systematical review and meta-analysis

PURPOSE

We conducted a systematic review and meta-analysis to evaluate the risk of early and late onset seizures following stroke mechanic thrombectomy (MT) compared with other systematic thrombolytic strategies.

METHODS

A literature search was conducted to identify articles covering databases (PubMed, Embase, and Cochrane Library) published from 2000 to 2022. The primary outcome was the incidence of post-stroke epilepsy or seizures following MT or in combination with intravenous thrombolytics therapy. Risk of bias was assessed by recording study characteristics. The study was conducted according to the PRISMA guidelines.

RESULTS

There were 1346 papers in the search results, and 13 papers were included in the final review.We identified 29,793 patients with stroke, of which 695 had seizures. Pooled incidence of post-stroke seizures had no significant difference between mechanic thrombolytic group and other thrombolytic strategy group (OR=0.95 (95%CI= 0.75-1.21); Z=0.43; p=0.67). In subgroup analysis, mechanic group have a lower risk of post-stroke early onset of seizures (OR=0.59 (95%CI=0.36-0.95); Z=2.18; p<0.05) but showed no significant difference in post-stroke late onset of seizures (OR=0.95 (95%CI= 0.68-1.32); Z=0.32; p=0.75).

CONCLUSIONS

MT may be associated with a lower risk of post-stroke early onset of seizures, despite MT does not affect the pooled incidence of post-stroke seizures compared with other systematic thrombolytic strategies.

Prevalence and prognosis of seizures among patients undergoing mechanical thrombectomy for acute ischemic stroke: A look at pre-2015 aha/asa guidelines update regarding endovascular treatment

BACKGROUND

Mechanical Thrombectomy (MT) is standard of care for eligible patients with Acute Ischemic Stroke (AIS) due to large vessel occlusion (LVO). With increasing use of MT, clinicians are more likely to encounter seizures, a potential complication of AIS treated with MT. Tracking future trends in the burden of post-stroke seizure associated with MT will require baseline pre-approval benchmark estimates of its frequency and outcomes.

METHODS

All patients with AIS who underwent MT (International Classification of Diseases, Ninth Revision, Clinical Modification; ICD-9-CM procedure code: 39.74) were identified from the National Inpatient Sample (NIS) 2006-2014, using appropriate ICD-9-CM codes. We identified a subset of patients with seizures using ICD-9-CM secondary discharge diagnoses codes 780.3x and 345.x. We computed the rate of seizures overall and across pre-specified demographic, clinical, and healthcare system-related variables. Finally, we assessed the independent association of mortality with seizures using a multivariable logistic regression model.

RESULTS

Of 30137 (weighted) patients with AIS who underwent MT, 1,363 (4.5%) had seizures. Patients who had seizures were younger, privately insured, or Medicaid beneficiaries, and frequently died in the hospital. There were no statistically significant differences between the seizures and no-seizures groups by race, sex, IV thrombolysis with recombinant tissue plasminogen activator, length of stay, and the number of medical comorbidities. However, patients who underwent MT and developed seizures had 75% higher odds of in-hospital mortality (adjusted OR 95% CI 1.75; 1.22-2.49).

CONCLUSION

In this nationwide sample, prior to the 2015 AHA/ASA guidelines update supporting MT use, seizures occurred in one of twenty patients with AIS treated with MT, and occurrence of seizure was independently associated with a nearly two-fold increase in the odds of in-hospitality death.

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.

Incidence and association of seizures in stroke patients following endovascular treatment: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Post-stroke seizures (PSSs) are some of the most common complications of stroke and are associated with poor outcomes in patients. Endovascular treatment (EVT) is the standard of care for patients with acute ischaemic stroke related large-vessel occlusion. However, whether EVT increases the risk of PSSs remains controversial; the association between PSSs and EVT is poorly understood.

METHODS

PubMed, Embase and the Cochrane Library were searched for relevant studies published from 1995 to 6 December 2021. The overall incidence of PSSs in patients treated with EVT and the separate incidence for all included studies in each subgroup, stratified by the type of treatment or time of onset, were calculated. The pooled odds ratio and confidence interval were calculated to quantify the effects of EVT on PSS occurrence.

RESULTS

In all, 946 studies were screened and 16 articles were included, with a total sample size of 12,664 patients; 7836 patients received EVT, of whom 460 had PSS. The pooled incidence of PSS after EVT was 5.8%, which was similar to patients treated with mechanical thrombectomy (5.3%), intra-arterial thrombolysis (6.8%) or bridging therapy (5.4%). The cumulative incidence of post-stroke epilepsy (6.0%) was almost twice that of acute symptomatic seizures (3.6%). The pooled odds ratio for the relationship between EVT and PSS was 1.91 (95% confidence interval 0.98-3.73).

CONCLUSIONS

The cumulative incidence of stroke patients treated with EVT who developed seizures was 5.8%, and EVT was non-significantly associated with the occurrence of seizures after stroke.

Epilepsy in Cerebrovascular Diseases: A Narrative Review

BACKGROUND

Epilepsy is a common comorbidity of cerebrovascular disease and an increasing socioeconomic burden.

OBJECTIVE

We aimed to provide an updated comprehensive review on the state of the art about seizures and epilepsy in stroke, cerebral haemorrhage, and leukoaraiosis.

METHODS

We selected English-written articles on epilepsy, stroke, and small vessel disease up until December 2021. We reported the most recent data about epidemiology, pathophysiology, prognosis, and management for each disease.

RESULTS

The main predictors for both ES and PSE are the severity and extent of stroke, the presence of cortical involvement and hemorrhagic transformation, while PSE is also predicted by younger age at stroke onset. Few data exist on physiopathology and seizure semiology, and no randomized controlled trial has been performed to standardize the therapeutic approach to post-stroke epilepsy.

CONCLUSION

Some aspects of ES and PSE have been well explored, particularly epidemiology and risk factors. On the contrary, few data exist on physiopathology, and existing evidence is mainly based on studies on animal models. Little is also known about seizure semiology, which may also be difficult to interpret by non-epileptologists. Moreover, the therapeutic approach needs standardization as regards indications and the choice of specific ASMs. Future research may help to better elucidate these aspects.

The Prognostic Utility of Electroencephalography in Stroke Recovery: A Systematic Review and Meta-Analysis

BACKGROUND

Improved ability to predict patient recovery would guide post-stroke care by helping clinicians personalize treatment and maximize outcomes. Electroencephalography (EEG) provides a direct measure of the functional neuroelectric activity in the brain that forms the basis for neuroplasticity and recovery, and thus may increase prognostic ability.

OBJECTIVE

To examine evidence for the prognostic utility of EEG in stroke recovery via systematic review/meta-analysis.

METHODS

Peer-reviewed journal articles that examined the relationship between EEG and subsequent clinical outcome(s) in stroke were searched using electronic databases. Two independent researchers extracted data for synthesis. Linear meta-regressions were performed across subsets of papers with common outcome measures to quantify the association between EEG and outcome.

RESULTS

75 papers were included. Association between EEG and clinical outcomes was seen not only early post-stroke, but more than 6 months post-stroke. The most studied prognostic potential of EEG was in predicting independence and stroke severity in the standard acute stroke care setting. The meta-analysis showed that EEG was associated with subsequent clinical outcomes measured by the Modified Rankin Scale, National Institutes of Health Stroke Scale, and Fugl-Meyer Upper Extremity Assessment (r = .72, .70, and .53 from 8, 13, and 12 papers, respectively). EEG improved prognostic abilities beyond prediction afforded by standard clinical assessments. However, the EEG variables examined were highly variable across studies and did not converge.

CONCLUSIONS

EEG shows potential to predict post-stroke recovery outcomes. However, evidence is largely explorative, primarily due to the lack of a definitive set of EEG measures to be used for prognosis.

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.

Effect of Reperfusion Therapies on Incidence of Early Post-Stroke Seizures

Objective: This study aimed to determine the effect of reperfusion therapies on the occurrence of early post-stroke seizures (PSS) in patients with acute ischemic stroke (AIS). Background: Reperfusion therapies are paramount to the treatment of stroke in the acute phase. However, their effect on the incidence of early seizures after an AIS remains unclear. Design and Methods: The stroke database at Hamad Medical Corporation was used to identify all patients who received reperfusion therapies for AIS from 2016 to 2019. They were matched with patients of similar diagnosis, gender, age, and stroke severity as measured by National Institutes of Health Stroke Scale (NIHSS) who did not receive such treatment. The rates of early PSS were calculated for each group. Results: The results showed that 508 patients received reperfusion therapies (342 had IV thrombolysis only, 70 had thrombectomies only, and 96 had received both), compared with 501 matched patients receiving standard stroke unit care. Patients who received reperfusion therapies were similar to their matched controls for mean admission NIHSS score (9.87 vs. 9.79; p = 0.831), mean age (53.3 vs. 53.2 years; p = 0.849), and gender distribution (85 vs. 86% men; p = 0.655). The group receiving reperfusion therapies was found to have increased stroke cortical involvement (62 vs. 49.3%, p < 0.001) and hemorrhagic transformation rates (33.5 vs. 18.6%, p < 0.001) compared with the control group. The rate of early PSS was significantly lower in patients who received reperfusion therapies compared with those who did not (3.1 vs. 5.8%, respectively; p = 0.042). When we excluded seizures occurring at stroke onset prior to any potential treatment implementation, the difference in early PSS rates between the two groups was no longer significant (2.6 vs. 3.9%, respectively; p = 0.251). There was no significant difference in early PSS rate based on the type of reperfusion therapy either (3.2% with thrombolysis, 2.9% with thrombectomy, and 3.1% for the combined treatment, p = 0.309). Conclusions: Treatment of AIS with either thrombectomy, thrombolysis, or both does not increase the risk of early PSS.

Acute symptomatic seizures and epilepsy after mechanical thrombectomy. A prospective long-term follow-up study

INTRODUCTION

New treatments for acute ischaemic stroke, such as mechanical thrombectomy, can achieve reperfusion of large ischaemic tissue. Some studies have suggested that reperfusion therapies can increase the risk of suffering acute symptomatic seizure (ASS) and poststroke epilepsy (PSE). The aim of the study was to determine the incidence of ASS and PSE in patients undergoing thrombectomy, and related factors.

PATIENTS AND METHODS

This was a retrospective single-centre study including patients with ischaemic stroke and NIHSS> 8 treated with thrombectomy with a follow-up ≥5 years. We evaluated several epidemiological, radiological, clinical and electroencephalographic variables.

RESULTS

Of the 344 included patients, 21 (6.1%) presented ASS, 53 (15.40%) died in the acute phase, and 13 (4.46%) died during the first year. The degree of reperfusion (p 0.029), advanced age (p 0.035), and haemorrhagic transformation (p 0.038) increased the risk of suffering ASS, with degree of reperfusion being an independent factor, OR 2.02 (1.21-4.64). The incidence of PSE was 4.12% in the first year, 3.72% in the second, and 1.61% in the fifth. The accumulated incidence at 5 years was 8.93%. Related risk factor for suffering PSE was ASS (p < 0.001), yielding an OR value of 2.00 (1.28-3.145).

CONCLUSIONS

Thrombectomy doesn´t increase the risk of ASS. A higher percentage of reperfusion, advanced age, and haemorrhagic transformation are associated with an increased risk of ASS. ASS is a risk factor for suffering PSE. In terms of mortality, having suffered ASS and/or PSE does not increase acute or long-term mortality.

Advances in the Development of Biomarkers for Poststroke Epilepsy

Stroke is the main cause of acquired epilepsy in elderly people. Poststroke epilepsy (PSE) not only affects functional recovery after stroke but also brings considerable social consequences. While some factors such as cortical involvement, hemorrhagic transformation, and stroke severity are associated with increased seizure risk, so far that remains controversial. In recent years, there are an increasing number of studies on potential biomarkers of PSE as tools for diagnosing and predicting epileptic seizures. Biomarkers such as interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), glutamate, and S100 calcium-binding protein B (S100B) in blood are associated with the occurrence of PSE. This review is aimed at summarizing the progress on potential biomarkers of PSE.

Incidence, predictors, and outcomes of post-thrombectomy seizures in the extended time window

Mechanical thrombectomy 6-24 h after the last time where a patient was known to be without signs or symptoms of a stroke is the standard of care for patients with a stroke due to large vessel occlusion. This is referred to as thrombectomy within an extended time window. There have been very few studies looking at patients who had seizures within the first week (early post-stroke seizures) following mechanical thrombectomy in this extended time window. Our study suggests that this group of patients does not have a higher incidence of early post stroke seizures. Our findings do reveal however, that patients who do have early post-stroke seizures may have a less favorable functional outcome at 90 days than those who did not develop early seizures. Hence, rapid identification and subsequent treatment of seizures in these patients is important.

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.

Early epileptic seizures in ischaemic stroke treated by mechanical thrombectomy: influence of rt-PA

BACKGROUND

The epileptogenicity of recombinant tissue-plasminogen activator (rt-PA) has been suggested, but seizures were not evaluated in randomised controlled trials.

OBJECTIVE

To evaluate whether rt-PA was associated with early seizures in a cohort of consecutive patients with cerebral ischaemia.

METHOD

We included consecutive adults with ischaemic stroke due to large-vessel occlusion from the North-of-France stroke network selected for a mechanical thrombectomy (MT). Patients without contraindication received i.v. rt-PA. We evaluated stroke severity with the National Institutes of Health Stroke Scale (NIHSS), and functional status with the modified Rankin scale (mRS), and recorded epileptic seizures occurring between the end of imaging and day 7. We performed statistics using propensity analyses.

RESULTS

We included 1638 patients (783 men, 47.8%; median age 71 years; median NIHSS score 16; 1007 treated by rt-PA, 61.5%), in whom 60 (3.7%) developed early epileptic seizures. After adjustment on propensity scores, early seizures were associated with infections [adjusted odds ratio (_adjOR) 2.86; 95% confidence interval (CI) 1.37-5.95] and delay between stroke recognition and end of MT (_adjOR 1.04 for 10 min more; 95% CI 1.01-1.08), but not with rt-PA (_adjOR 1.35; 95% CI 0.55-3.33). The propensity-matched analysis of 343 pairs of patients found no difference in the occurrence of early seizures between those with and without rt-PA (p = 0.386).

CONCLUSION

We found no significant association between rt-PA and early epileptic seizures. If rt-PA has the potential for epileptogenicity, the magnitude of the effect should be modest compared to its favourable effect on functional outcome.

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.

Acute symptomatic seizures and epilepsy after mechanical thrombectomy

PURPOSE

The purpose of this study was to assess the incidence of acute symptomatic seizures and poststroke epilepsy (PSE) in a well-characterized cohort of patients treated with mechanical thrombectomy. In addition, we aimed to describe the dynamics of blood markers of brain injury in patients that developed PSE.

METHODS

Participants of the prospective AnStroke Trial of anesthesia method during mechanical thrombectomy were included and acute symptomatic seizures and PSE ascertained by medical records review. Blood markers neurofilament light (NFL), tau, glial fibrillary acidic protein (GFAP), S100 calcium-binding protein B (S100B), and neuron-specific enolase (NSE) were assessed.

RESULTS

A total of 90 patients with acute anterior ischemic stroke were included. Median National Institutes of Health Stroke Scale (NIHSS) at admission to hospital was 18 (IQR 15-22). Recanalization was achieved in 90%. No patients had epilepsy prior to the ischemic stroke. Four patients (4.4%) had acute symptomatic seizures and four patients (4.4%) developed PSE during the follow-up time (to death or last medical records review) of 0-4.5 years (median follow-up 1070 days IQR 777-1306), resulting in a two-year estimated PSE risk of 5.3% (95%CI: 0.2-10.4%). Blood markers of brain injury (NFL, tau, GFAP, S100B, and NSE) were generally above the cohort median in patients that developed PSE.

CONCLUSIONS

The incidence of PSE after mechanical thrombectomy was low in our cohort. All blood biomarkers displayed interesting sensitivity and specificity. However, the number of PSE cases was small and more studies are needed on risk factors for PSE after mechanical thrombectomy. The potential of blood markers of brain injury markers to contribute to assessment of PSE risk should be explored further. This article is part of the Special Issue "Seizures & Stroke".

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".