ImportanceAcute symptomatic seizures occurring within 7 days after ischemic stroke may be associated with an increased mortality and risk of epilepsy. It is unknown whether the type of acute symptomatic seizure influences this risk.ObjectiveTo compare mortality and risk of epilepsy following different types of acute symptomatic seizures.Design, Setting, and ParticipantsThis cohort study analyzed data acquired from 2002 to 2019 from 9 tertiary referral centers. The derivation cohort included adults from 7 cohorts and 2 case-control studies with neuroimaging-confirmed ischemic stroke and without a history of seizures. Replication in 3 separate cohorts included adults with acute symptomatic status epilepticus after neuroimaging-confirmed ischemic stroke. The final data analysis was performed in July 2022.ExposuresType of acute symptomatic seizure.Main Outcomes and MeasuresAll-cause mortality and epilepsy (at least 1 unprovoked seizure presenting >7 days after stroke).ResultsA total of 4552 adults were included in the derivation cohort (2547 male participants [56%]; 2005 female [44%]; median age, 73 years [IQR, 62-81]). Acute symptomatic seizures occurred in 226 individuals (5%), of whom 8 (0.2%) presented with status epilepticus. In patients with acute symptomatic status epilepticus, 10-year mortality was 79% compared with 30% in those with short acute symptomatic seizures and 11% in those without seizures. The 10-year risk of epilepsy in stroke survivors with acute symptomatic status epilepticus was 81%, compared with 40% in survivors with short acute symptomatic seizures and 13% in survivors without seizures. In a replication cohort of 39 individuals with acute symptomatic status epilepticus after ischemic stroke (24 female; median age, 78 years), the 10-year risk of mortality and epilepsy was 76% and 88%, respectively. We updated a previously described prognostic model (SeLECT 2.0) with the type of acute symptomatic seizures as a covariate. SeLECT 2.0 successfully captured cases at high risk of poststroke epilepsy.Conclusions and RelevanceIn this study, individuals with stroke and acute symptomatic seizures presenting as status epilepticus had a higher mortality and risk of epilepsy compared with those with short acute symptomatic seizures or no seizures. The SeLECT 2.0 prognostic model adequately reflected the risk of epilepsy in high-risk cases and may inform decisions on the continuation of antiseizure medication treatment and the methods and frequency of follow-up.
Highlights
Stroke cases continue to rise in the COVID-19 pandemic
Stroke presents late in severe COVID-19 patients and early in mild cases
Patients with large vessel occlusion were younger and had higher NIHSS
Hypercoagulability and inflammation in COVID-19 are related to stroke
Other cause
should be considered as a stroke etiology in COVID-19 patients
Introduction:
Coronavirus disease 2019 (COVID-19) has been associated with stroke, particular characteristics of these patients are not fully understood. The adequate management of these patients depends on the comprehension of factors such as temporality, clinical presentation and etiology. We hypothesize there is a differential temporal relationship between COVID-19 severity and stroke onset.
Methods:
Considering PRISMA guidelines, a systematic review of the literature as of July 2020 was conducted and registered on PROSPERO. Pubmed and Scopus studies reporting patients with COVID-19 and stroke were included. Clinical, sociodemographic and laboratory characteristics of patients were extracted and analyzed.
Results:
Forty-seven studies and 176 patients were included, with a mean age of 63.1 years (SD= 16 n=122), most of them were males (63.2% n=171). The most frequent etiology was cryptogenic (40.9% n=66), and a mean National Institute of Health Stroke Scale of 14.4 points was found (SD= 8.6 n=73). Large vessel occlusion (LVO) was reported in 65.9% patients (n=91) and these patients were younger with greater stroke severity. D-dimer, C-reactive protein, fibrinogen, ferritin and lactate dehydrogenase were elevated in most patients with reported findings. Most patients had severe COVID-19. The mean time from onset of respiratory symptoms to stroke was 9 days (SD=9.9), a shorter time was noted in those with mild and moderate disease compared with the longest time in severe disease, this difference was statistically significant (p< 0.001).
Conclusions:
There is a trend between the severity of COVID-19 and time to stroke onset, in which mild disease is associated with earlier stroke than severe disease. Age and stroke severity are related to the development of LVO. Inflammation and hypercoagulability markers are elevated in this disease, we propose to consider hypercoagulability secondary to COVID-19 as an underlying cause of stroke in these patients.
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