Association of Mortality and Risk of Epilepsy With Type of Acute Symptomatic Seizure After Ischemic Stroke and an Updated Prognostic Model

Abstract

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.

The SeLECT 2.0 Score—Significance of Treatment With Antiseizure Medication

“…To the Editor Congratulations to Sinka et al on their recent article introducing the SeLECT 2.0 score. We have been using the original SeLECT score in the past and are pleased that there is an update incorporating acute symptomatic status epilepticus.…”

“…Following current guidelines, we are hesitant to treat most acute symptomatic seizures with antiseizure medication (ASM) beyond the acute phase of stroke. Therefore, we were intrigued by the finding that ASM therapy after acute symptomatic seizures was independently associated with a reduced mortality (adjusted hazard ratio, 0.3; 95% CI, 0.1-0.6), and we wonder what the reason for this association might be. Despite the retrospective study design, can the authors tell at what time and for how long patients were treated with ASMs?…”

The SeLECT 2.0 Score—Significance of Treatment With Antiseizure Medication—Reply

“…Furthermore, early ASM treatment itself may positively influence the outcome. Detectable seizures and status epilepticus, but also subclinical epileptic activity on the electroencephalogram, may negatively impact outcome after stroke. Early ASMs effectively suppress seizures, thereby potentially reducing mortality.…”

“…Despite several limitations, our results warrant further exploration through prospective controlled trials. The SeLECT 2.0 score may serve as a valuable tool to facilitate the recruitment of an enriched population for such prospective trials.…”

“…In Reply We read with keen interest the intriguing commentary by Doerrfuss and colleagues on our article entitled, “Association of Mortality and Risk of Epilepsy With Type of Acute Symptomatic Seizure After Ischemic Stroke and an Updated Prognostic Model.” The authors highlighted the finding of decreased mortality in those receiving early treatment with antiseizure medications (ASMs) following acute symptomatic seizures after ischemic stroke.…”