Identifying patients at risk of acute symptomatic seizure after 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.

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.

Acute symptomatic seizures in the emergency room: predictors and characteristics

Background

When treating patients with epileptic seizures in the emergency room (ER), it is of paramount importance to rapidly assess whether the seizure was acute symptomatic or unprovoked as the former points to a potentially life-threatening underlying condition. In this study, we seek to identify predictors and analyze characteristics of acute symptomatic seizures (ASS).

Methods

Data from patients presenting with seizures to highly frequented ERs of two sites of a university hospital were analyzed retrospectively. Seizures were classified as acute symptomatic or unprovoked according to definitions of the International League Against Epilepsy. Univariate and multivariate analysis were conducted to identify predictors; furthermore, characteristics of ASS were assessed.

Results

Finally, 695 patients were included, 24.5% presented with ASS. Variables independently associated with ASS comprised male sex (OR 3.173, 95% CI 1.972–5.104), no prior diagnosis of epilepsy (OR 11.235, 95% CI 7.195–17.537), and bilateral/generalized tonic–clonic seizure semiology (OR 2.982, 95% CI 1.172–7.588). Alcohol withdrawal was the most common cause of ASS (74.1%), with hemorrhagic stroke being the second most prevalent etiology. Neuroimaging was performed more often in patients with the final diagnosis of ASS than in those with unprovoked seizures (82.9% vs. 67.2%, p < 0.001). Patients with ASS were more likely to receive acute antiseizure medication in the ER (55.9% vs. 30.3%, p < 0.001).

Conclusions

In one quarter of patients presenting to the ER after an epileptic fit, the seizure had an acute symptomatic genesis. The independently associated variables may help to early identify ASS and initiate management of the underlying condition.

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.

National Institutes of Health Stroke Scale (NIHSS) on admission predicts acute symptomatic seizure risk in ischemic stroke: a population-based study involving 135,117 cases

The National Institutes of Health Stroke Scale (NIHSS) score is the most frequently used score worldwide for assessing the clinical severity of a stroke. Prior research suggested an association between acute symptomatic seizures after stroke and poorer outcome. We determined the frequency of acute seizures after ischemic stroke in a large population-based registry in a central European region between 2004 and 2016 and identified risk factors for acute seizures in univariate and multivariate analyses. Additionally, we determined the influence of seizures on morbidity and mortality in a matched case-control design. Our analysis of 135,117 cases demonstrated a seizure frequency of 1.3%. Seizure risk was 0.6% with an NIHSS score at admission <3 points and increased up to 7.0% with >31 score points. Seizure risk was significantly higher in the presence of acute non-neurological infections (odds ratio: 3.4; 95% confidence interval: 2.8-4.1). A lower premorbid functional level also significantly increased seizure risk (OR: 1.7; 95%CI: 1.4-2.0). Mortality in patients with acute symptomatic seizures was almost doubled when compared to controls matched for age, gender, and stroke severity. Acute symptomatic seizures increase morbidity and mortality in ischemic stroke. Their odds increase with a higher NIHSS score at admission.

Correlation of blood biomarkers with early-onset seizures after an acute stroke event

INTRODUCTION

Blood biomarkers have not been widely studied in stroke-related seizures. In this study, we aimed to describe clinical factors and biomarkers present during acute stroke and to analyze their association with early-onset seizures.

METHODS

We retrospectively evaluated a panel of 14 blood biomarkers in 1115 patients with ischemic and hemorrhagic stroke. Biomarkers were normalized and standardized using Z scores. We also recorded stroke and epilepsy-related variables, including stroke severity (National Institute of Health Stroke Scale [NIHSS] scores), type, and causes, time from onset of stroke to occurrence of early seizures, and type of seizure. Adjusted logistic regression models were built to identify clinical variables and biomarkers independently associated with early seizures.

RESULTS

Mean ± standard deviation (SD) age was 72.3 ± 13.2 years, and 56.8% of the patients were men. Thirty-eight patients (3.9%) developed early seizures with a median time to onset of 1 day (interquartile range (IQR), 0-4). A higher NIHSS score (odds ratio [OR] = 1.046; 95% confidence interval (CI): 1.001-1.094; p = 0.044) and hemorrhagic stroke (OR = 2.133; 95% CI: 1.010-4.504; p = 0.047) were independently associated with a greater risk of early seizures. Independent blood biomarkers predictive of early seizures were lower levels of tumor necrosis factor receptor 1 (TNF-R1) (<0.013) (p = 0.006; OR = 3.334; 95% CI: 1.414-7.864) and higher levels of neural cell adhesion molecule (NCAM) (>0.326) (p = 0.009; OR = 2.625; 95% CI: 1.271-5.420). The predictive power of the regression model was greater when clinical variables were combined with blood biomarkers (73.5%; 95% CI: 65.1%-81.9%) than when used alone (64%; 95% CI: 55%-72.9%).

CONCLUSION

Higher NCAM and lower TNF-R1 levels may help predict the occurrence of early seizures. The combined use of these biomarkers and clinical variables could be useful for identifying patients at risk of seizures. 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).

Clinical Outcome After Mechanical Thrombectomy in Patients with Diabetes with Major Ischemic Stroke of the Anterior Circulation

BACKGROUND

Among patients with acute ischemic stroke treated with mechanical thrombectomy (MT), patients with diabetes (DP) show a poorer outcome compared with patients without diabetes (NDP). This study aims to provide a comprehensive analysis of factors associated with unfavorable outcome in DP receiving MT for stroke of the anterior circulation.

METHODS

This study included 317 of 498 consecutive patients who received interventional treatment for acute ischemic stroke in the terminal internal carotid artery and/or middle cerebral artery, including 46 DP. The study data included pre- and posttreatment stroke computed tomography, including perfusion data, collateral status, treatment data including treatment times, pre-existing cardiovascular risk factors, cerebrovascular events, comorbidities, laboratory parameters, and medication. Neurologic status was assessed at baseline (National Institute of Health Stroke Scale [NIHSS]/modified Rankin Scale [mRS]) and after 90 days (mRS 90).

RESULTS

Compared with NDP, DP showed a significantly poorer outcome (mRS90 >2) (P < 0.05). Collateralization and infarct core size did not differ between groups, whereas the penumbra was significantly smaller in DP than in NDP (P < 0.05). The poorer mRS90 outcome (mRS90 > 2) in DP was associated with poor collaterals (P = 0.01) and hyperglycemia on admission (P < 0.05). Shorter time to reperfusion was associated with favorable mRS90 in the NDP (P < 0.001) but not the DP (P = 0.49) group. In univariate logistic regression, the following parameters were significantly associated with mRS90: diabetes, hyperglycemia at admission, time to reperfusion, and the NIHSS score (P < 0.05 each). In multivariate analyses and partition regression models of all variables, DP with admission hyperglycemia (≥132 mg/dL) and older age (≥66 years) showed a particularly poor outcome.

CONCLUSIONS

The main factors for an unfavorable outcome of DP after MT are admission hyperglycemia, age, and NIHSS score.

Characteristics of the ischemic stroke patients whose seizures occur at stroke presentation at a single institution in Eastern China

PURPOSE

We compared clinical characteristics and outcomes of the early-onset seizure post-stroke patients who had seizures occurring at stroke presentation (SSP) with other patients without SSP at a single institution in Eastern China.

METHODS

We reviewed 20,947 ischemic stroke patients in our hospital electronic medical records system from January 2007 to December 2016. Among them, there were 91 (0.43%) patients with early-onset seizure post-stroke. Among these 91 patients, there were 35 (0.16%) SSP patients and another 56 (0.27%) were designated as non SSP patients because they also had early-onset seizure post-stroke, but without SSP. We compared the clinical presentations of the SSP patients with those of the non SSP patients including baseline stroke risk factors, and 10-year Kaplan-Meier death risk after their first stroke.

RESULTS

In the SSP patients, 25.7% of them presented with posterior circulation infarction, whereas only 12.5% of the non SSP patients had this condition (P<0.05). In contrast, 17.1% of the SSP patients were being treated with antiepileptic drugs at discharge whereas 37.5% of the non SSP patients received such treatment (P<0.05). The percentage of SSP patients with temporal lobe lesions was less than in non SSP patients (P<0.05). However, brain stem and thalamus lesions were more frequently seen in SSP patients than non in SSP patients (P<0.05). The risk factors for ischemic stroke including a history of hypertension, diabetes mellitus, hyperlipidemia and atrial fibrillation were the same in these two groups (P>0.05). In the SSP patients group, the 10-year risk of death was 36.9% after the initial seizure incident, and in the non SSP patients group, the 10-year death risk was 40.1%, but this difference between the two groups was not significant (P>0.05).

CONCLUSIONS

Ischemic stroke patients with SSP had some unique signs that included a higher incidence of posterior circulation infarction than non SSP patients.