Post-stroke Everything

PURPOSE OF REVIEW

This review aims at providing updates on selected post-stroke complications. We examined recent advances in diagnosing and treating the following post-stroke complications: cognitive impairment, epilepsy, depression, fatigue, tremors, dysphagia, and pain.

RECENT FINDINGS

Advances in understanding the mechanisms of post-stroke complications, in general, are needed despite advances made in understanding, treating, and preventing these complications. There are growing progresses in integrating new tools to diagnose post-stroke cognitive impairment. The potential role of acute stroke reperfusion treatment in post-stroke epilepsy and its impact on other stroke complications is getting more transparent. Post-stroke depression remains underestimated and new tools to diagnose depression after stroke are being developed. New promising pharmacological approaches to treating post-stroke pain are emerging. Tremors related to stroke are poorly understood and under-evaluated, while treatment towards post-stroke dysphagia has benefited from new non-pharmacological to pharmacological approaches.

CONCLUSIONS

An integrative approach to stroke complications and collaborations between providers across specialties are more likely to improve stroke outcomes.

Poststroke Seizures and the Risk of Dementia Among Young Stroke Survivors

BACKGROUND AND OBJECTIVES

The effect of new-onset seizures in young stroke survivors on the subsequent development of dementia is poorly understood. This study aimed to assess the association between new onset of seizure and dementia in a population-based study of patients with stroke.

METHODS

The IBM Watson Health MarketScan Commercial Claims and Encounters database for the years 2005-2014 served as the data source for this study. Using the International Classification of Diseases, Ninth Revision (ICD-9), we identified patients aged 18-60 years with ischemic strokes (ISs; 433.x1, 434.x1, and 436) and hemorrhagic strokes (HSs; 430, 431, 432.0, 432.1, and 432.9) between January 1, 2006, and December 31, 2009, which constituted our baseline study cohort. At baseline, all included participants were free of claims for dementia, brain tumors, toxin exposure, traumatic brain injury, and neuroinfectious diseases, identified using ICD-9 codes. They had at least 1-year continuous enrollment before the index stroke diagnosis and 5 years after, with no seizure claims within 1 year after the index date. The exposure of interest was seizures: a time-dependent variable. The study outcome of interest was dementia (ICD-9: 290.0, 290.10-13, 290.20-21, 290.3, 290.40-43, 291.2, 292.82, 294.10-11, 294.20-21, 294.8, 331.0, 331.11, 331.19, and 331.82), which occurred during the follow-up period from January 1, 2010, to December 31, 2014. A Cox proportional hazards regression model was applied to calculate the hazard ratio (HR) and 95% CI for the independent association of seizures with the occurrence of dementia.

RESULTS

At the end of the baseline period, we identified 23,680 patients with stroke (IS: 20,642 and HS: 3,038). The cumulative incidence of seizure was 6.7%, 6.4%, and 8.3% for all strokes, IS, and HS, respectively. The cumulative incidence of dementia was 1.3%, 1.4%, and 0.9% for all strokes, IS, and HS, respectively. After multivariable adjustment, young patients with stroke who developed seizures had a greater risk of dementia compared with those without seizures (all strokes adjusted HR: 2.53, 95% CI 1.84-3.48; IS: 2.52, 1.79-3.53; HS: 2.80, 1.05-7.43).

DISCUSSION

These findings suggest that the onset of seizures in young stroke survivors is associated with a 2.53 times increased risk of developing dementia.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that poststroke seizures increase the probability of dementia in young stroke survivors.

Seizures and epilepsy in patients with ischaemic stroke

BACKGROUND

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

CONCLUSION

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

Risk models to predict late-onset seizures after stroke: A systematic review

BACKGROUND AND PURPOSE

We performed a systematic review to evaluate available risk models to predict late seizure onset among stroke survivors.

METHODS

We searched major databases (PubMed, SCOPUS, and Cochrane Library) from inception to October 2020 for articles on the development and/or validation of risk models to predict late seizures after a stroke. The impact of models to predict late-onset seizures was also assessed. We included seven articles in the final analysis. For each of these studies, we evaluated the study design and scope of predictors analyzed to derive each model. We assessed the performance of the models during internal and external validation in terms of discrimination and calibration.

RESULTS

Three studies focused on ischemic stroke alone, with c-statistic values ranging from 0.73 to 0.77. The SeLECT model from Switzerland was externally validated in Italian, German, and Austrian cohorts where c-statistics ranged from 0.69 to 0.81. This model along with the PSEiCARe model, were internally validated and calibration performance was provided for both models. The CAVS and CAVE models reported on the risk of late-onset seizures in patients with hemorrhagic stroke. The CAVS model derivation cohort was racially diverse. The CAVS model's c-statistic was 0.76, while the CAVE model had a c-statistic of 0.81. Calibration and internal validation were not performed for either study. The CAVS model, created from a Finnish population, was externally validated in American and French cohorts, with c-statistics of 0.73 and 0.69, respectively. Finally, the two studies focusing on both types of stroke came from the PoSERS and INPOSE models. Neither model provided c-statistics, calibration metrics, internal or external validation information. We found no evidence of the presence of impact studies to assess the effect of adopting late-onset seizure risk models after stroke on clinical outcomes.

CONCLUSION

The SeLECT model was the only model developed in line with proposed guidelines for appropriate model development. The model, which was externally validated in a very similar and homogeneous population, may need to be tested in a more racially/ethnic diverse and younger population; testing the SeLECT model, accounting for overall brain health is likely to improve the identification of high-risk patients for late post stroke seizures.

Seizures and Epilepsy After Stroke: Epidemiology, Biomarkers and Management

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.

Treatment with Diazepam in Acute Stroke Prevents Poststroke Seizures: A Substudy of the EGASIS Trial

OBJECTIVE

The frequency of seizures after stroke is high, with a severe impact on the quality of life. However, little is known about their prevention. Therefore, we investigated whether early administration of diazepam prevents the development of seizures in acute stroke patients.

METHODS

We performed a substudy of the EGASIS trial, a multicenter double-blind, randomized trial in which acute stroke patients were treated with diazepam or placebo for 3 days. Follow-up was after 2 weeks and 3 months. The occurrence of seizures was registered prospectively as one of the prespecified secondary outcomes.

RESULTS

784 EGASIS patients were eligible for this substudy (389 treated with diazepam [49.6%] and 395 treated with placebo [50.4%]). Seizures were reported in 19 patients (2.4% of the total patient group). Seizures occurred less frequently in patients treated with diazepam (1.5 vs. 3.3% in the placebo group); however, this difference was only statistically significant in patients with a cortical anterior circulation infarction (0.9% in the diazepam group vs. 4.6% in the placebo group, incidence rate ratio 0.20, 95% CI: 0.05-0.78, p = 0.02, NNT = 27).

CONCLUSION

We found that a 3-day treatment with diazepam after acute cortical anterior circulation stroke prevents the occurrence of seizures in the first 3 months following 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.

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

OBJECTIVE

Despite the wide utilization of mechanical thrombectomy (MT) for acute ischemic stroke treatment, little is known about the incidence of early post-thrombectomy seizures, its predictors, and association with long-term outcome.

METHODS

Using a prospective registry of mechanical thrombectomy in ischemic stroke between January 2013 and July 2017, we identified patients who developed a seizure within 7 days (early seizure) of qualifying event. Backward stepwise regression analysis was used to assess independent predictors of seizure occurrence and the association between seizure and functional outcome (modified Rankin scale of 0-2 vs. ≥3).

RESULTS

A total of 459 patients were included in the final analysis. Mean age was 67.5 (SD 15.1), and 49.9% of patients were female. Successful recanalization (TICI≥2B) was achieved in 92.8% of patients. Eleven (2.4%) patients developed at least one seizure. Only an Alberta Stroke Program Early CT (ASPECT) score of <6 was independently associated with the occurrence of early seizures [Odds ratio, 95% confidence interval: 8.188, (2.219-30.214); P = .002]. On multivariate analysis, early seizures were associated with 90-day mortality rate [OR,6.487; 95% confidence interval, (1.481-28.405); P = .013] and poor functional outcome (OR, 4.7; 95% confidence interval (1.08-20.83); p = .039).

CONCLUSION

In the studied cohort, 2.4% of ischemic stroke patients treated with MT developed at least one seizure within 7 days of stroke onset. A low ASPECT score was associated with the occurrence of early seizures. The occurrence of seizures was associated with 90-day mortality and poor functional outcome.

Small Hyperintensities in the Area of the Perforating Arteries in Patients with Seizure

Background/Aim: We previously observed spotty hyperintense lesions in the region of the perforating arteries on peri-ictal diffusion-weighted imaging (DWI); however, no report has formally described these findings. The aim of this study was to investigate focal intensities on peri-ictal DWI, and to evaluate the clinical significance of these lesions. Methods: We conducted a retrospective review of 677 consecutive patients with seizure who completed peri-ictal DWI within 24 h after seizure onset. Patients were grouped according to the presence or absence of diffusion hyperintense lesions (DHLs) in the region of the perforating arteries. We compared clinical and imaging characteristics between these 2 groups. Results: Among 677 patients, 23 patients (3.4%) had DHLs. Analyses of apparent diffusion coefficient values and fluid attenuated inversion recovery images suggested that DHLs were acute or subacute ischemic lesions that had appeared prior to seizure onset. Patients with DHLs were more likely to be older in age, have atrial fibrillation, and coronary artery disease, and have more severe deep white matter hyperintensity or leukoaraiosis compared to patients without DHLs. Conclusion: DHLs detected on peri-ictal DWI may represent incidental acute cerebral microinfarcts in the aging brain, especially in patients with small vessel disease.

Poststroke epilepsy: update and future directions

Stroke is among the most common causes of epilepsy after middle age. Patients with poststroke epilepsy (PSE) differ in several respects from patients with other forms of structural-metabolic epilepsy; not least in age, age-related sensitivity to side effects of antiepileptic drugs (AEDs), and specific drug-drug interaction issues related to secondary-stroke prophylaxis. Encouragingly, there has lately been remarkable activity in the study of PSE. Three developments in PSE research deserve particular focus. First, large prospective trials have established the incidence and risk factors of PSE in the setting of modern stroke care. Stroke severity, cortical location, young age, and haemorrhage remain the most important risk factors. Second, although more studies are needed, epidemiological data indicate that the risk of PSE may be influenced, for instance, by statin treatment. Third, studies are emerging regarding the treatment and prognosis of PSE. Levetiracetam and lamotrigine may be well tolerated treatment options and seizure freedom is achieved in at least a similar proportion of patients as in other epilepsies. Furthermore, new animal models such as photothrombotic stroke gives hope of a more clear understanding of PSE epileptogenesis in the near future. In summary, PSE shows indications of maturing into an independent epilepsy research field. This review summarizes recent advances in our understanding of PSE and provides an update on management issues such as diagnosis, AED selection, and prognosis. Finally, future research challenges in the field are outlined.

Cognitive deterioration in adult epilepsy: Does accelerated cognitive ageing exist?

A long-standing concern has been whether epilepsy contributes to cognitive decline or so-called 'epileptic dementia'. Although global cognitive decline is generally reported in the context of chronic refractory epilepsy, it is largely unknown what percentage of patients is at risk for decline. This review is focused on the identification of risk factors and characterization of aberrant cognitive trajectories in epilepsy. Evidence is found that the cognitive trajectory of patients with epilepsy over time differs from processes of cognitive ageing in healthy people, especially in adulthood-onset epilepsy. Cognitive deterioration in these patients seems to develop in a 'second hit model' and occurs when epilepsy hits on a brain that is already vulnerable or vice versa when comorbid problems develop in a person with epilepsy. Processes of ageing may be accelerated due to loss of brain plasticity and cognitive reserve capacity for which we coin the term 'accelerated cognitive ageing'. We believe that the concept of accelerated cognitive ageing can be helpful in providing a framework understanding global cognitive deterioration in epilepsy.