Hypertension on admission is associated with a lower risk of early seizures after stroke

Risk Factors for Post-Stroke Seizures in a Tertiary Care Center: A Case-Control Study

Purpose

Stroke is the second leading cause of global deaths. Post-stroke seizures (PSS) can lead to lasting complications, such as prolonged hospitalizations, increased disability rates, and higher mortality. Our study investigates the associated factors that contribute to post-stroke seizures in patients at a local tertiary hospital.

Patients and Methods

We designed a case-control study where patients admitted with PSS were recruited with consent. Controls admitted for stroke without seizure were then included. Suitability based on exclusion criteria was ensured before recording their sociodemographic and clinical data. An EEG was performed and read by two certified neurologists before the data was analyzed.

Results

We recruited 180 participants, 90 cases and 90 matched controls. Gender (p=0.013), race (p=0.015), dyslipidemia (p<0.001), prior stroke (p<0.031), large artery atherosclerosis (p<0.001), small vessel occlusions (p<0.001), blood pressure on presentation (p<0.028) and thrombolysis administration (p<0.029) were significantly associated with the occurrence of PSS. An increase in odds of PSS was observed in the male gender (1.974), dyslipidemia (3.480), small vessel occlusions (4.578), and in participants with epileptiform changes on EEG (3.630). Conversely, lower odds of PSS were seen in participants with high blood pressure on presentation (0.505), large artery atherosclerosis (0.266), and those who underwent thrombolysis (0.319).

Conclusion

This study emphasized that identifying post-stroke seizures may be aided by EEGs and recognizing at-risk groups, which include males of Chinese descent in Asia, dyslipidemia, small vessel occlusions, those with low to normal blood pressure on presentation, and epileptiform changes in EEGs.

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.

Early Epileptic Seizures after Ischemic Stroke: Their Association with Stroke Risk Factors and Stroke Characteristics

Background and Objectives: A growing number of stroke survivors face various stroke complications, including new-onset epileptic seizures (ESs). Post-stroke ESs are divided into early and late ESs based on the time of onset after stroke. Early ESs are associated with worse stroke outcomes, longer hospitalization and an increased risk of late ESs. A variety of risk factors for early ESs are being studied in order to prevent their occurrence. Therefore, we aim to determine the association of early ESs with ischemic stroke risk factors and characteristics. Materials and Methods: A total of 166 patients, treated for ischemic stroke in the Hospital of Lithuanian University of Health Sciences Kaunas Clinics, were enrolled in a prospective cohort study. Initially, data about stroke risk factors, localization, severity and treatment were collected, followed by an observation period of 14 days for early ESs. Results: Early ESs occurred in 11 (6.6%) participants. The probability of early ESs after ischemic stroke among males and females (LogRank = 1.281; p > 0.05), younger (≤65 y) and older (>65 y) participants (LogRank = 0.129; p > 0.05) was the same. The presence of ischemic stroke risk factors, such as atrial fibrillation (LogRank = 0.004; p > 0.05), diabetes mellitus (LogRank = 1.168; p > 0.05) and dyslipidemia (LogRank = 0.092; p > 0.05), did not increase the probability of early ESs. However, participants without a prior history of arterial hypertension (LogRank = 4.453; p < 0.05) were more likely to develop early ESs. Stroke localization (anterior versus posterior) (LogRank = 0.011; p > 0.05), stroke severity (LogRank = 0.395; p > 0.05) and type of treatment (specific versus non-specific) (LogRank = 1.783; p > 0.05) did not affect the probability of early ESs.

Effect of Primary Prophylactic Antiseizure Medication for Seizure Prevention Following Intracerebral Hemorrhage in the ERICH Study

OBJECTIVES

Intracerebral hemorrhage (ICH) has the highest morbidity and mortality rate of any stroke subtype and clinicians often administer prophylactic antiseizure medications (ASMs) as a means of preventing post-stroke seizures, particularly following lobar ICH. However, evidence for ASM efficacy in preventing seizures and reducing disability is lacking given limited randomized trials. Herein, we report analysis from a large prospective observational study that evaluates the effect of primary prophylactic ASM administration on seizure occurrence and disability following ICH.

MATERIALS AND METHODS

Primary analysis was performed on 1630 patients with ICH enrolled in the ERICH study. A propensity score for administration of prophylactic ASM was developed and patients were matched by the closest propensity score (difference < 0.1). McNemar's test was used to compare occurrence of in-hospital seizure and disability, defined by modified Rankin Score (mRS) ≥ 3 at 3 months post ICH.

RESULTS

Of the 815 matched pairs of patients treated with primary prophylactic ASM, there was no significant difference in seizure occurrence (p = 0.4631) or disability (p = 0.4653). Subset analysis of 280 matched pairs of patients with primary lobar ICH similarly revealed no significant difference in seizure occurrence (p = 0.1011) or disability (p = 1.00) between prophylactically treated and untreated patients.

CONCLUSIONS

Although current guidelines do not recommend primary prophylactic ASM following ICH, clinical use remains widespread. Data from the ERICH study did not find an association between administering primary prophylactic ASM and preventing seizures or reducing disability following ICH, thus providing evidence to influence clinical practice and patient care.

Early Post-Stroke Seizures in Acute Ischemic Stroke: A Prospective Cohort Study

Introduction

Stroke is the most common cause of epilepsy in the adult population. Post-stroke seizures (PSSs) are classified into early-onset seizures (ES) and late-onset (LS). ES can significantly affect the clinical outcome and occurrence of LS.

Methods

We analyzed data from a prospective cohort of acute ischemic stroke patients between June 2018 and May 2020 in a neurology unit at a tertiary hospital. We screened all acute stroke patients and included consecutive patients older than 18 years of age, presenting with acute, first-ever neuroimaging-confirmed ischemic stroke. We excluded patients with a previous stroke, transient ischemic attacks, hemorrhagic stroke, cerebral venous thrombosis, prior history of seizures, or any other epileptogenic comorbidity. ES were classified as spontaneous seizures occurring within 1 week of the stroke. The main outcome assessed was the occurrence of ES. The secondary outcome was to determine predictors of ES and create an ES prediction score.

Results

We screened 432 patients; of them, 291 were enrolled. ES occurred in 37 patients (12.7%). Cortical location (OR: 4.2), large artery disease subtype (OR: 2.9), mRS at presentation (OR: 1.4), use of anticoagulants (OR: 2.6), and hypertension (OR: 0.3) were significantly associated with the occurrence of ES. Patients with ES had a statistically significant worse clinical outcome at 3 months follow-up (P = 0.0072).

Conclusion

We could formulate an ES prediction tool using the following components: (a) cortical location, (b) large vessel stroke, (c) mRS at admission, (d) anticoagulant use, and (e) presence of hypertension. This tool might help in treating patients at high risk for ES with prophylactic ASD, thereby preventing seizures and their complications.

Risk factors for early-onset seizures after stroke: A systematicreview and meta-analysis of 18 observational studies

OBJECTIVES

To systematically evaluate the risk factors of early-onset seizures after stroke, in order to better provide evidence-based results for early detection, identification, targeted prevention, and treatment of this disease.

METHODS

PubMed, EMBASE, The Cochrane Library, CNKI, and WanFang databases were searched to collect relevant studies on the risk factors of early-onset seizures after stroke from January 2010 to January 2020. Meta-analysis of all included studies was performed by using RevMan version 5.3 and Stata version 14.0 software.

RESULTS

Eighteen case-control studies with a total sample size of 13,289 cases, including 813 cases with early-onset seizures after stroke, and 12,476 cases with non-early-onset seizures after stroke were included. The results of meta-analysis showed that cortical involvement [Odds Ratio (OR) = 5.00, 95%Confidence Interval (CI) (2.85, 8.74), p < .00001], cerebral infarction with hemorrhagic transformation [OR = 2.77, 95%CI (1.87, 4.11), p < .00001] and intracerebral hemorrhage [OR = 1.83, 95%CI (1.13, 2.97), p = .01]-related factors showed greater association with the occurrence of early-onset seizures after stroke.

CONCLUSIONS

These findings suggest that cortical involvement, intracerebral hemorrhage, and cerebral infarction with hemorrhagic transformation are important predictors and risk factors for early seizures after stroke, while the patient's gender, age, NHISS score, alcoholism, smoking, high blood pressure, diabetes, atrial fibrillation, dyslipidemia, receiving surgical treatment, and reperfusion therapy showed no association with the occurrence of early-onset seizures after stroke.

Early seizures after ischemic stroke: focus on thrombolysis

INTRODUCTION

Stroke is a significant underlying cause of epilepsy. Seizures due to ischemic stroke (IS) are generally categorized into early seizures (ESs) and late seizures (LSs). Seizures in thrombolysis situations may raise the possibility of other etiology than IS.

AIM

We overtook a systematic review focusing on the pathogenesis, prevalence, risk factors, detection, management, and clinical outcome of ESs in IS and in stroke/thrombolysis situations. We also collected articles focusing on the association of recombinant tissue-type plasminogen activator (rt-PA) treatment and epileptic seizures.

RESULTS

We have identified 37 studies with 36,775 participants. ES rate was 3.8% overall in patients with IS with geographical differences. Cortical involvement, severe stroke, hemorrhagic transformation, age (<65 years), large lesion, and atrial fibrillation were the most important risk factors. Sixty-one percent of ESs were partial and 39% were general. Status epilepticus (SE) occurred in 16.3%. 73.6% had an onset within 24 h and 40% may present at the onset of stroke syndrome. Based on EEG findings seizure-like activity could be detected only in approximately 18% of ES patients. MRI diffusion-weighted imaging and multimodal brain imaging may help in the differentiation of ischemia vs. seizure. There are no specific recommendations with regard to the treatment of ES.

CONCLUSION

ESs are rare complications of acute stroke with substantial burden. A significant proportion can be presented at the onset of stroke requiring an extensive diagnostic workup.

Statin use associated with lower risk of epilepsy after intracranial haemorrhage: A population-based cohort study

AIMS

To examine the association between statin use before and after intracranial haemorrhage (ICH) and the risk of poststroke epilepsy (PSE).

METHODS

Patients with new-onset ICH between 2004 and 2012 were identified from the Taiwan National Health Insurance Research Database. The main outcome was the occurrence of epilepsy after stroke. Multivariable Cox regression modelling was used to estimate the association between statin use and the risk of PSE, with poststroke medication exposures being treated as time-dependent variables.

RESULTS

A total of 7435 patients with ICH were enrolled with a median follow-up of 17.6 months. Within the study cohort, 709 patients developed PSE. Poststroke, but not prestroke, stain use was associated with a reduced risk of PSE (adjusted hazard ratio 0.62, 95% confidence interval 0.42-0.90, P = 0.01). In subanalyses, a trend of a dose-response relationship was observed. A significant PSE risk reduction was correlated with a higher cumulative statin dose. Moreover, the risk of PSE was lower in patients receiving moderate-to-high-intensity statin therapy (adjusted hazard ratio 0.37, 95% confidence interval 0.18-0.75, P = 0.01). Lipophilic and hydrophilic statins were similar with regard to their associations with the reduced risk of PSE.

CONCLUSIONS

Statin therapy may reduce the risk of PSE after ICH, especially with moderate-to-high therapy intensity. Further research is needed to understand the mechanisms underlying the potential protective effects of statins against PSE in this patient population.