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Pascarella A, Manzo L, Gasparini S, Marsico O, Abelardo D, Torino C, Cianci V, Iudice A, Bisulli F, Bonanni P, Caggia E, D'Aniello A, Di Bonaventura C, DiFrancesco JC, Domina E, Dono F, Gambardella A, Fortunato F, Marini C, Marrelli A, Matricardi S, Morano A, Paladin F, Renna R, Piccioli M, Striano P, Ascoli M, La Neve A, Le Piane E, Orsini A, Di Gennaro G, Aguglia U, Ferlazzo E. Perampanel in post-stroke epilepsy: Clinical practice data from the PERampanel as Only Concomitant antiseizure medication (PEROC) study. J Neurol Sci 2024; 462:123106. [PMID: 38925069 DOI: 10.1016/j.jns.2024.123106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/13/2024] [Accepted: 06/19/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Post-stroke epilepsy (PSE) is one of the most common causes of acquired epilepsy. Nevertheless, there is limited evidence regarding the clinical profile of antiseizure medications (ASMs) in PSE. This study aims to evaluate the 12-month effectiveness and tolerability of perampanel (PER) used as only add-on treatment in patients with PSE in a real-world setting. METHODS We performed a subgroup analysis of PSE patients included in a previous retrospective, longitudinal, multicentre observational study on adults. Treatment discontinuation, seizure frequency and adverse events were collected at 3, 6 and 12 months. Sub-analyses by early (≤1 previous ASM) or late PER add-on were also conducted. RESULTS Our analysis included 56 individuals with PSE, characterized by varying initial treatment modalities and timeframes relative to disease onset. We found notable retention rates (92.8%, 83.7%, and 69% at 3, 6, and 12 months), with treatment withdrawal mainly due to poor tolerability. One year after PER introduction, seizure frequency significantly reduced, with a responder rate (≥50% reduction) of 83.9% and a seizure-free rate of 51.6%. Adverse events occurred in 25 (46.3%) patients, mainly dizziness, irritability, and behavioural disorders. No major statistical differences were found between early (30 patients, 53.6%) and late add-on groups, except for a higher 6-month responder rate in the early add-on group. CONCLUSION Adjunctive PER was effective and well-tolerated in patients with PSE in a real-world setting. Perampanel demonstrated good efficacy and safety as both early and late add-on treatment, making it a compelling option for this unique patient population.
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Affiliation(s)
- Angelo Pascarella
- Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, Italy; Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy
| | - Lucia Manzo
- Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, Italy; Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy
| | - Sara Gasparini
- Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, Italy; Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy
| | - Oreste Marsico
- Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, Italy; Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy
| | - Domenico Abelardo
- Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, Italy; Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy
| | - Claudia Torino
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension of Reggio Calabria, National Research Council, Institute of Clinical Physiology, Reggio Calabria, Italy
| | - Vittoria Cianci
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy
| | - Alfonso Iudice
- Department of Neurosciences, Section of Neurology, University of Pisa, Pisa, Italy
| | - Francesca Bisulli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Paolo Bonanni
- Epilepsy and Clinical Neurophysiology Unit, Scientific Institute, IRCCS Eugenio Medea, Treviso, Italy
| | | | | | - Carlo Di Bonaventura
- Epilepsy Unit, Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
| | | | | | - Fedele Dono
- Department of Neuroscience, Imaging and Clinical Science, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Antonio Gambardella
- Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, Italy; Neurologic Clinic, Magna Græcia University of Catanzaro, Catanzaro, Italy
| | - Francesco Fortunato
- Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, Italy; Neurologic Clinic, Magna Græcia University of Catanzaro, Catanzaro, Italy
| | - Carla Marini
- Child Neurology and Psychiatric Unit, G. Salesi Pediatric Hospital, Azienda Ospedaliera-Universitaria delle Marche, Ancona, Italy
| | - Alfonso Marrelli
- Neurophysiopathology Unit, Epilepsy Center, San Salvatore Hospital, L'Aquila, Italy
| | | | - Alessandra Morano
- Epilepsy Unit, Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
| | | | - Rosaria Renna
- Neurological Clinic and Stroke Unit, "Cardarelli" Hospital, Naples, Italy
| | - Marta Piccioli
- UOC Neurology, PO San Filippo Neri, ASL Roma 1, Rome, Italy
| | - Pasquale Striano
- IRCCS Istituto Giannina Gaslini, Genova, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy
| | | | - Angela La Neve
- Dipartimento di Scienze Mediche di Base, Neuroscienze e Organi di Senso, Università di Bari
| | - Emilio Le Piane
- Dipartimento di Neurologia, Ospedale Pugliese-Ciaccio, Catanzaro, Italy
| | - Alessandro Orsini
- Pediatric Neurology, Pediatric Department, AOUP Santa Chiara Univeristy Hospital, Pisa, Italy
| | - Gianfranco Di Gennaro
- Dipartimento di Scienze della Salute, Scuola di Medicina, Università Magna Graecia di Catanzaro, Italy
| | - Umberto Aguglia
- Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, Italy; Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy
| | - Edoardo Ferlazzo
- Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, Italy; Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy.
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Xie C, Zhao W, Zhang X, Liu J, Liu J, Xia Z. The Progress of Poststroke Seizures. Neurochem Res 2024; 49:887-894. [PMID: 38294644 DOI: 10.1007/s11064-023-04079-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 11/15/2023] [Accepted: 11/29/2023] [Indexed: 02/01/2024]
Abstract
A stroke is one of the most common fatal diseases of the nervous system, and the number of strokes per year has increased substantially in recent years. Epilepsy is a poststroke complication that greatly affects the prognosis of patients and reduces their quality of survival. Effective avoidance of causative factors can reduce the risk of a poststroke seizure. However, while many studies have been devoted to elucidating the pathogenesis of poststroke seizures, the literature lacks a comprehensive understanding of the pathogenic mechanism. This article briefly presents the current definition, risk factors, pathogenesis, and prognosis of poststroke seizures based on reported studies and literature reviews, aiming to enrich the available knowledge of this disease.
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Affiliation(s)
- Cong Xie
- Department of Gerontology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, 16766 Jingshi Road, Jinan, 250014, China
| | - Wei Zhao
- Department of Gerontology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, 16766 Jingshi Road, Jinan, 250014, China
| | - Xu Zhang
- Department of Gerontology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, 16766 Jingshi Road, Jinan, 250014, China
| | - Ju Liu
- Laboratory of Microvascular Medicine, Medical Research Center, Shandong Provincial Qianfoshan Hospital, Shandong University, 16766 Jingshi Road, Jinan, 250014, China
| | - Jinzhi Liu
- Department of Gerontology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, 16766 Jingshi Road, Jinan, 250014, China.
- Department of Neurology, Liaocheng People's Hospital and Liaocheng Clinical School of Shandong First Medical University, 67 Dongchang West Road, Liaocheng, 252000, China.
- Department of Gerontology, Cheeloo College of Medicine, Shandong Provincial Qianfoshan Hospital, Shandong University, 44 Wenhua West Road, Jinan, 250012, China.
- Department of Geriatric Neurology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, 16766 Jingshi Road, Jinan, 250014, China.
| | - Zhangyong Xia
- Department of Neurology, Liaocheng People's Hospital, Shandong University, No. 27 South Shanda Road, Jinan, Shandong, 250012, PR China.
- Department of Neurology, Liaocheng People's Hospital and Liaocheng Hospital Affiliated to Shandong First Medical University, 67 Dongchang West Road, Liaocheng, Shandong, 252000, PR China.
- Department of Neurology, the Second People's Hospital of Liaocheng, No. 306, Health Street, Liaocheng, Shandong, 252000, PR China.
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Winter Y, Sandner K, Vieth T, Gonzalez-Escamilla G, Stuckrad-Barre SV, Groppa S. Third-Generation Antiseizure Medication in the Treatment of Benzodiazepine-Refractory Status Epilepticus in Poststroke Epilepsy: A Retrospective Observational Register-Based Study. CNS Drugs 2023; 37:929-936. [PMID: 37784006 PMCID: PMC10570217 DOI: 10.1007/s40263-023-01039-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Status epilepticus in poststroke epilepsy is a challenging condition because of multiple vascular comorbidities and the advanced age of patients. Data on third-generation antiseizure medication (ASM) in this condition are limited. The aim of this study was to evaluate the efficacy of third-generation ASMs in the second- or third-line therapy of benzodiazepine-refractory status epilepticus in poststroke epilepsy following acute ischemic stroke. METHODS Data on the effectiveness of third-generation ASMs in patients with status epilepticus in poststroke epilepsy were gathered from two German Stroke Registries and the Mainz Epilepsy Registry. We included only cases with epilepsy remote to the ischemic event. No patients with acute symptomatic seizures were included. The following third-generation ASMs were included: brivaracetam, lacosamide, eslicarbazepine, perampanel, topiramate, and zonisamide. The assessment of effectiveness was based on seizure freedom within 48 h since the start of therapy with the respective ASM. Seizure freedom was evaluated both clinically (clinical evaluation at least three times per day) and by daily electroencephalogram records. RESULTS Of the 138 patients aged 70.8 ± 8.1 years with benzodiazepine-refractory status epilepticus in ischemic poststroke epilepsy, 33 (23.9%) were treated with lacosamide, 24 (17.4%) with brivaracetam, 23 (16.7%) with eslicarbazepine, 21 (15.2%) with perampanel, 20 (14.5%) with topiramate, and 17 (12.3%) with zonisamide. Seizure freedom within 48 h was achieved in 66.7% of patients with lacosamide, 65.2% with eslicarbazepine, 38.1% with perampanel, 37.5% with brivaracetam, 35.0% with topiramate, and 35.3% with zonisamide (p < 0.05 for comparison of lacosamide or eslicarbazepine to other ASMs). CONCLUSIONS Based on these data, lacosamide and eslicarbazepine might be more favorable in the treatment of refractory status epilepticus in poststroke epilepsy, when administered as second- or third-line ASMs before anesthesia. Because of the fact that these ASMs share the same mechanism of action (slow inactivation of sodium channels), our findings could motivate further research on the role that this pharmaceutical mechanism of action has in the treatment of poststroke epilepsy. CLINICAL TRIAL REGISTRATION This study was registered at ClinicalTrials.gov (NCT05267405).
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Affiliation(s)
- Yaroslav Winter
- Department of Neurology, Mainz Comprehensive Epilepsy and Sleep Medicine Center, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr 1, 55131 Mainz, Germany
- Department of Neurology, Philipps-University Marburg, Marburg, Germany
| | - Katharina Sandner
- Department of Neurology, Mainz Comprehensive Epilepsy and Sleep Medicine Center, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr 1, 55131 Mainz, Germany
| | - Thomas Vieth
- Rudolf Frey Educational Clinic, Johannes Gutenberg University, Mainz, Germany
| | - Gabriel Gonzalez-Escamilla
- Focus Program Translational Neuroscience (FTN), Department of Neurology, Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Sergiu Groppa
- Focus Program Translational Neuroscience (FTN), Department of Neurology, Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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He Z, Li J. The therapeutic effects of lacosamide on epilepsy-associated comorbidities. Front Neurol 2023; 14:1063703. [PMID: 37006477 PMCID: PMC10062524 DOI: 10.3389/fneur.2023.1063703] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 03/02/2023] [Indexed: 03/18/2023] Open
Abstract
Epilepsy is a chronic neurological disorder associated with severe social and psychological effects, and most epilepsy patients often report at least one comorbidity. Accumulating evidence have suggested that lacosamide, a new generation of anti-seizure medications, may exhibit efficacy in the management of both epilepsy and its related comorbidities. Therefore, this narrative review aimed to elucidate the recent advancements regarding the therapeutic role of lacosamide in epilepsy-associated comorbidities. The possible pathophysiological mechanisms between epilepsy and epilepsy-associated comorbidities have been also partially described. Whether lacosamide improves cognitive and behavioral functions in patients with epilepsy has not been conclusively established. Some studies support that lacosamide may alleviate anxiety and depression in epilepsy patients. In addition, lacosamide has been found to be safe and effective in the treatment of epilepsy in people with intellectual disabilities, epilepsy of cerebrovascular etiology, and epilepsy associated with brain tumors. Moreover, lacosamide treatment has demonstrated fewer side effects on other systems. Hence, future larger and higher quality clinical studies are needed to further explore both the safety and efficacy of lacosamide in the treatment of epilepsy-associated comorbidities.
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Chen YS, Lai MC, Chen TS, Tseng YH, Li YJ, Huang CW. Effectiveness and Safety of Lacosamide, A Third-generation Anti-seizure Medication, for Poststroke Seizure and Epilepsy: A Literature Review. Curr Neuropharmacol 2023; 21:2126-2133. [PMID: 37340744 PMCID: PMC10556369 DOI: 10.2174/1570159x21666230616114255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 06/17/2023] Open
Abstract
Advances in stroke treatment have resulted in a dramatic reduction in stroke mortality. Nevertheless, poststroke seizures and epilepsy are issues of clinical importance affecting survivors. Additionally, stroke is the most common cause of epilepsy in older adults. Although numerous antiseizure medications exist, studies are needed to provide robust evidence of the efficacy and tolerability of these medicines for treating poststroke seizures and epilepsy. Crucially, the newer generations of antiseizure medications require testing. Lacosamide, a third-generation antiseizure medication approved for treating localization-related epilepsy, has a novel mechanism of selectively enhancing the slow inactivation of sodium channels. This literature review evaluated whether lacosamide is effective and safe for the treatment of poststroke seizures and epilepsy. This review critically analyzed studies published in major academic databases (Pubmed, Embase, and Cochrane Library) from inception through June 2022 regarding the interaction of lacosamide with poststroke seizures and epilepsy. We included clinical prospective, retrospective, and case studies on patients with poststroke seizure and epilepsy, lacosamide as a treatment for seizures, neuroprotection in animal models of seizures, and the safety of lacosamide when coadministering anticoagulants. Clinical studies revealed lacosamide to be an effective antiseizure medication with high efficacy and tolerability in patients with poststroke seizures and epilepsy. In animal models, lacosamide proved effective at seizure reduction and neuroprotection. Pharmacokinetic studies demonstrated the safety of lacosamide when coadministering conventional and new anticoagulants. The literature suggests that Lacosamide is a promising candidate antiseizure medication for patients with poststroke seizures and epilepsy.
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Affiliation(s)
- Yu-Shiue Chen
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Chi Lai
- Department of Pediatrics, Chi-Mei Medical Center, Tainan, Taiwan
| | - Tsang-Shan Chen
- Department of Neurology, Tainan Sin-Lau Hospital, Tainan, Taiwan
| | - Yung-Hsin Tseng
- Department of Pharmacy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ya Jhen Li
- Kun-Yen Medical Library, National Cheng Kung University, Tainan, Taiwan
| | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Efficacy and safety of antiseizure medication in post-stroke epilepsy. Seizure 2022; 100:109-114. [PMID: 35834881 DOI: 10.1016/j.seizure.2022.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/03/2022] [Accepted: 07/05/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Specific antiseizure medications (ASM) would improve the outcome in post-stroke epilepsy (PSE). The aim of this multicenter observational study was to compare different antiseizure monotherapies in PSE. METHODS We collected the data from 207 patients with PSE who did not change their initial antiseizure monotherapy during the period of 12 months. Efficacy was assessed by a standardized three month seizure frequency and seizure freedom. Safety was estimated by the reported side effects. RESULTS The mean three month seizure frequency was 1.9 ± 3.1 on eslicarbazepine, 2.1 ± 3.2 on lacosamide, 3.4 ± 4.4 on levetiracetam, 4.3 ± 6.8 on lamotrigine, and 5.1 ± 7.3 on valproate (p < 0.05 for eslicarbazepine or lacosamide in comparison with levetiracetam, lamotrigine and valproate, respectively). The lowest seizure frequency and the highest seizure freedom was observed on ASMs acting via the slow inactivation of sodium channels in comparison to other mechanisms of action (0.7 ± 0.9 vs 2.2 ± 2.4, p < 0.01). Among side effects, the most frequently reported were vertigo (25%) and tiredness (15.9%). They were similar in all investigated groups of ASM. The independent factors increasing seizure frequency that were identified in multiple regression analyses were increased size of infarction, cortical involvement, hemorrhagic transformation, neurological deficits at admission and functional impairment. Administration of ASM with the mechanism of action via the slow inactivation of sodium channels was an independent factor decreasing the seizure frequency. CONCLUSION Our data show that antiseizure medications acting via the slow inactivation of sodium channels, such as lacosamide and eslicarbazepine, are well tolerated and might be associated with better seizure control in PSE.
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Chang RS, Leung WC, Vassallo M, Sykes L, Battersby Wood E, Kwan J. Antiepileptic drugs for the primary and secondary prevention of seizures after stroke. Cochrane Database Syst Rev 2022; 2:CD005398. [PMID: 35129214 PMCID: PMC8819727 DOI: 10.1002/14651858.cd005398.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Seizures after stroke are an important clinical problem and may result in poor outcomes. The indications of antiepileptic drugs (AEDs) for seizure prophylaxis after stroke remain unclear. This is an updated version of the Cochrane Review previously published in 2014. OBJECTIVES To assess the effects of AEDs for the primary and secondary prevention of seizures after stroke. For primary prevention, we aimed to assess whether AEDs reduce the likelihood of seizures in people who have a stroke but do not have a seizure. For secondary prevention, we aimed to assess whether AEDs reduce the likelihood of further seizures in people who have a stroke and at least one post-stroke seizure. SEARCH METHODS We searched the following databases on 9 March 2021: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid, 1946 to March 08, 2021). CRS Web includes randomised or quasi-randomised controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organisation International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), and the Specialised Registers of Cochrane Review Groups including Epilepsy and Stroke. We also checked the reference lists of articles retrieved from these searches. SELECTION CRITERIA We selected randomised and quasi-randomised controlled studies that recruited participants with a clinical diagnosis of stroke, either ischaemic or haemorrhagic. We excluded studies that only recruited participants with subarachnoid haemorrhage, subdural haemorrhage, extradural haemorrhage, or other non-stroke diagnoses such as tumour- or infection-related infarction or haemorrhage. We also excluded studies that recruited only participants who had undergone neurosurgery. We included participants of all ages suffering any seizure type who were assigned to AEDs or placebo groups. DATA COLLECTION AND ANALYSIS In accordance with standard methodological procedures expected by The Cochrane Collaboration, two review authors independently assessed trials for inclusion before evaluating trial risk of bias and extracting relevant data. The primary outcome assessed was the proportion of participants who experienced seizures in the follow-up period. We presented results as summary risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous outcomes and mean differences (MDs) with 95% CIs for continuous outcomes. Where we had sufficient data, we calculated random-effects (Mantel-Haenszel) meta-analyses for dichotomous outcomes; otherwise, we reported results narratively. We used the I2 statistic to analyse statistical heterogeneity. We planned to use funnel plots to assess publication bias in meta-analyses with at least 10 included studies. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS Two studies with a total of 856 subjects were included. AEDs were not shown to be effective in primary prophylaxis of post-stroke seizure (RR 0.65, 95% CI 0.34 to 1.26; 2 studies, 856 participants; moderate-certainty evidence). The first study was a randomised double-blind study comparing valproic acid with placebo for primary seizure prevention up to one year after stroke. The study included 72 adults with intracerebral haemorrhage. There was no difference in the risk of post-stroke seizures (RR 0.88, 95% CI 0.35 to 2.16) or of death (RR 1.20, 95% CI 0.40 to 3.58). The second study was a substudy on the use of diazepam in acute stroke. It was a randomised double-blind study, comparing a three-day diazepam treatment versus placebo for primary seizure prevention up to three months after stroke in 784 adults with acute stroke. There was no evidence of a difference in the risk of post-stroke seizures for all stroke or subgroups of haemorrhagic or ischaemic stroke (RR for all stroke 0.47, 95% CI 0.18 to 1.22). In a subgroup analysis of anterior circulation cortical infarcts, primary prophylaxis with diazepam was associated with a reduced risk of post-stroke seizures (RR 0.21, 95% CI 0.05 to 0.95). Risks of mortality did not differ between the diazepam and the placebo group at two weeks (RR 0.84, 95% CI 0.56 to 1.26) and three months follow-up (RR 0.95, 95% CI 0.72 to 1.26). We assessed both studies to be at a low overall risk of bias. Using the GRADE approach, we assessed the overall certainty of the evidence as low to moderate. AUTHORS' CONCLUSIONS There is insufficient evidence to support the routine use of AEDs on the primary and secondary prevention of seizures after stroke. Further well-conducted studies are warranted for this important clinical problem.
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Affiliation(s)
- Richard S Chang
- Division of Neurology, Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | - William Cy Leung
- Division of Neurology, Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | | | - Lucy Sykes
- Hampshire Hospitals NHS Foundation Trust, Hampshire, UK
| | | | - Joseph Kwan
- Department of Brain Sciences, Imperial College London, London, UK
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Costa C, Nardi Cesarini E, Eusebi P, Franchini D, Casucci P, De Giorgi M, Calvello C, Romoli M, Parnetti L, Calabresi P. Incidence and Antiseizure Medications of Post-stroke Epilepsy in Umbria: A Population-Based Study Using Healthcare Administrative Databases. Front Neurol 2022; 12:800524. [PMID: 35095743 PMCID: PMC8790124 DOI: 10.3389/fneur.2021.800524] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 11/29/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction: Post-stroke epilepsy (PSE) requires long-term treatment with antiseizure medications (ASMs). However, epidemiology of PSE and long-term compliance with ASM in this population are still unclear. Here we report, through population-level healthcare administrative data, incidence, risk factors, ASM choice, and ASM switch over long-term follow-up. Materials and Methods: This is a population-based retrospective study using Umbria healthcare administrative database. Population consisted of all patients with acute stroke, either ischaemic or hemorrhagic, between 2013 and 2018. ICD-9-CM codes were implemented to identify people with stroke, while PSE was adjudicated according to previously validated algorithm, such as EEG and ≥1 ASM 7 days after stroke. Results: Overall, among 11,093 incident cases of acute stroke (75.9% ischemic), 275 subjects presented PSE, for a cumulative incidence of 2.5%. Patients with PSE were younger (64 vs. 76 years), more frequently presented with hemorrhagic stroke, and had longer hospital stay (15.5 vs. 11.2 days) compared with patients without PSE. Multivariable Cox proportional hazards models confirmed that PSE associated with hemorrhagic stroke, younger age, and longer duration of hospital stay. Levetiracetam was the most prescribed ASM (55.3%), followed by valproate and oxcarbazepine. Almost 30% of patients prescribed with these ASMs switched treatment during follow-up, mostly toward non-enzyme-inducing ASMs. About 12% of patients was prescribed ASM polytherapy over follow-up. Conclusions: Post-stroke epilepsy is associated with hemorrhagic stroke, younger age, and longer hospital stay. First ASM is switched every one in three patients, suggesting the need for treatment tailoring in line with secondary prevention.
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Affiliation(s)
- Cinzia Costa
- Neurology Clinic, Department of Medicine and Surgery, Santa Maria della (S.M.) Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Elena Nardi Cesarini
- Neurology Clinic, Department of Medicine and Surgery, Santa Maria della (S.M.) Misericordia Hospital, University of Perugia, Perugia, Italy.,UOC Neurologia, Ospedale di Senigallia, Senigallia, Italy
| | - Paolo Eusebi
- Health ICT Service, Regional Health Authority of Umbria, Perugia, Italy
| | - David Franchini
- Health ICT Service, Regional Health Authority of Umbria, Perugia, Italy
| | - Paola Casucci
- Health ICT Service, Regional Health Authority of Umbria, Perugia, Italy
| | | | - Carmen Calvello
- Neurology Clinic, Department of Medicine and Surgery, Santa Maria della (S.M.) Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Michele Romoli
- Neurology Clinic, Department of Medicine and Surgery, Santa Maria della (S.M.) Misericordia Hospital, University of Perugia, Perugia, Italy.,Neurology and Stroke Unit, "Maurizio Bufalini" Hospital, Cesena, Italy
| | - Lucilla Parnetti
- Neurology Clinic, Department of Medicine and Surgery, Santa Maria della (S.M.) Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Paolo Calabresi
- Neurologia, Dipartimento Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy.,Neurologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
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Evidence for Inhibitory Perturbations on the Amplitude, Gating, and Hysteresis of A-Type Potassium Current, Produced by Lacosamide, a Functionalized Amino Acid with Anticonvulsant Properties. Int J Mol Sci 2022; 23:ijms23031171. [PMID: 35163091 PMCID: PMC8835568 DOI: 10.3390/ijms23031171] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/11/2022] [Accepted: 01/19/2022] [Indexed: 02/05/2023] Open
Abstract
Lacosamide (Vimpat®, LCS) is widely known as a functionalized amino acid with promising anti-convulsant properties; however, adverse events during its use have gradually appeared. Despite its inhibitory effect on voltage-gated Na+ current (INa), the modifications on varying types of ionic currents caused by this drug remain largely unexplored. In pituitary tumor (GH3) cells, we found that the presence of LCS concentration-dependently decreased the amplitude of A-type K+ current (IK(A)) elicited in response to membrane depolarization. The IK(A) amplitude in these cells was sensitive to attenuation by the application of 4-aminopyridine, 4-aminopyridine-3-methanol, or capsaicin but not by that of tetraethylammonium chloride. The effective IC50 value required for its reduction in peak or sustained IK(A) was calculated to be 102 or 42 µM, respectively, while the value of the dissociation constant (KD) estimated from the slow component in IK(A) inactivation at varying LCS concentrations was 52 µM. By use of two-step voltage protocol, the presence of this drug resulted in a rightward shift in the steady-state inactivation curve of IK(A) as well as in a slowing in the recovery time course of the current block; however, no change in the gating charge of the inactivation curve was detected in its presence. Moreover, the LCS addition led to an attenuation in the degree of voltage-dependent hysteresis for IK(A) elicitation by long-duration triangular ramp voltage commands. Likewise, the IK(A) identified in mouse mHippoE-14 neurons was also sensitive to block by LCS, coincident with an elevation in the current inactivation rate. Collectively, apart from its canonical action on INa inhibition, LCS was effective at altering the amplitude, gating, and hysteresis of IK(A) in excitable cells. The modulatory actions on IK(A), caused by LCS, could interfere with the functional activities of electrically excitable cells (e.g., pituitary tumor cells or hippocampal neurons).
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Zöllner JP, Schmitt FC, Rosenow F, Kohlhase K, Seiler A, Strzelczyk A, Stefan H. Seizures and epilepsy in patients with ischaemic stroke. Neurol Res Pract 2021; 3:63. [PMID: 34865660 PMCID: PMC8647498 DOI: 10.1186/s42466-021-00161-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/11/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Johann Philipp Zöllner
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | | | - Felix Rosenow
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Konstantin Kohlhase
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Alexander Seiler
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Hermann Stefan
- Department of Neurology - Biomagnetism, University Hospital Erlangen, Erlangen, Germany
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Zhao L, Li J, Kälviäinen R, Jolkkonen J, Zhao C. Impact of drug treatment and drug interactions in post-stroke epilepsy. Pharmacol Ther 2021; 233:108030. [PMID: 34742778 DOI: 10.1016/j.pharmthera.2021.108030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/01/2021] [Accepted: 11/01/2021] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Lanqing Zhao
- Department of Sleep Medicine Center, The Shengjing Affiliated Hospital, China Medical University, Shenyang, Liaoning, PR China
| | - Jinwei Li
- Department of Stroke Center, The First Affiliated Hospital, China Medical University, Shenyang, Liaoning, PR China
| | - Reetta Kälviäinen
- Kuopio Epilepsy Center, Neurocenter, Kuopio University Hospital, Full Member of ERN EpiCARE, Kuopio, Finland; Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Jukka Jolkkonen
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland.
| | - Chuansheng Zhao
- Department of Neurology, The First Affiliated Hospital, China Medical University, Shenyang, Liaoning, PR China.
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Galovic M, Ferreira-Atuesta C, Abraira L, Döhler N, Sinka L, Brigo F, Bentes C, Zelano J, Koepp MJ. Seizures and Epilepsy After Stroke: Epidemiology, Biomarkers and Management. Drugs Aging 2021; 38:285-299. [PMID: 33619704 PMCID: PMC8007525 DOI: 10.1007/s40266-021-00837-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2021] [Indexed: 12/14/2022]
Abstract
Stroke is the leading cause of seizures and epilepsy in older adults. Patients who have larger and more severe strokes involving the cortex, are younger, and have acute symptomatic seizures and intracerebral haemorrhage are at highest risk of developing post-stroke epilepsy. Prognostic models, including the SeLECT and CAVE scores, help gauge the risk of epileptogenesis. Early electroencephalogram and blood-based biomarkers can provide information additional to the clinical risk factors of post-stroke epilepsy. The management of acute versus remote symptomatic seizures after stroke is markedly different. The choice of an ideal antiseizure medication should not only rely on efficacy but also consider adverse effects, altered pharmacodynamics in older adults, and the influence on the underlying vascular co-morbidity. Drug-drug interactions, particularly those between antiseizure medications and anticoagulants or antiplatelets, also influence treatment decisions. In this review, we describe the epidemiology, risk factors, biomarkers, and management of seizures after an ischaemic or haemorrhagic stroke. We discuss the special considerations required for the treatment of post-stroke epilepsy due to the age, co-morbidities, co-medication, and vulnerability of stroke survivors.
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Affiliation(s)
- Marian Galovic
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland.
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK.
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK.
| | - Carolina Ferreira-Atuesta
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Laura Abraira
- Epilepsy Unit, Department of Neurology, Vall d'Hebron Hospital Universitari, Barcelona, Spain
- Universitat Autonoma de Barcelona, Bellaterra, Spain
| | - Nico Döhler
- Specialist Clinic for Neurorehabilitation, Kliniken Beelitz, Beelitz-Heilstätten, Germany
| | - Lucia Sinka
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland
| | - Francesco Brigo
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Italy
| | - Carla Bentes
- Department of Neurosciences and Mental Health (Neurology), Hospital de Santa Maria-CHLN, Lisboa, Portugal
| | - Johan Zelano
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Matthias J Koepp
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK
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Villanueva V, Sánchez-Álvarez JC, Carreño M, Salas-Puig J, Caballero-Martínez F, Gil-Nagel A. Initiating antiepilepsy treatment: An update of expert consensus in Spain. Epilepsy Behav 2021; 114:107540. [PMID: 33243687 DOI: 10.1016/j.yebeh.2020.107540] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/09/2020] [Accepted: 10/09/2020] [Indexed: 12/28/2022]
Abstract
Following publication in 2014 of the International League Against Epilepsy (ILAE) official report changing the definition of epilepsy, a number of questions remain unresolved in regard to deciding when to start treatment and to the choice of a particular antiseizure medication (ASM). This study uses a Delphi method to update consensus among a panel of experts on the initiation of epilepsy treatment in order to provide insight regarding those questions. The study was undertaken in four phases. Firstly, a multi-center steering committee met to review relevant bibliography and to draft a questionnaire. Secondly, a panel of neurologists specialized in epilepsy was selected and convened. Thirdly, an online survey was carried out in two rounds. Fourthly, the final results were discussed at a face-to-face meeting of the steering committee to draw conclusions. The final questionnaire focused on three independent sections: the decision to commence ASM in different clinical situations, the choice of initial monotherapy depending on the type of epilepsy and the patient's age/sex (including childbearing potential), and the choice of initial monotherapy depending on comorbidity. In these two latter sections, fourteen ASMs approved for monotherapy use by the EMA and available in Spain were considered. Regarding the decision as to when to commence treatment, the results show agreement exists to initiate treatment following a first generalized tonic-clonic seizure or a focal seizure if the electroencephalography (EEG) reveals epileptiform activity, if the MRI reveals a lesion, or when it occurs in elderly patients. With respect to the choice of initial monotherapy depending on the type of epilepsy and the patient's age/sex profile, it is agreed to avoid valproic acid (VPA) in women with childbearing potential, with levetiracetam (LEV) and lamotrigine (LTG) being the preferable options in generalized epilepsy. In focal epilepsy, the options are broader, particularly in men, and include the most recent ASMs approved for monotherapy. In the elderly, LEV, lacosamide (LCM), eslicarbazepine acetate (ESL) and LTG are considered the most suitable drugs for initiating treatment. With regard to comorbidities, the recommendation is to avoid enzyme inducing ASMs, with LEV, the most recent ASMs approved for monotherapy and LTG being the preferred options. In conclusion, as the ILAE definition states, there are different situations that lead to treatment initiation after a first seizure. When choosing the first ASM, the type of epilepsy, childbearing potential and drug-drug interaction are key factors.
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Affiliation(s)
- Vicente Villanueva
- Unidad Epilepsia Refractaria, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
| | | | - Mar Carreño
- Unidad de Epilepsia, Hospital Clínic, Barcelona, Spain
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