Risk of Post-stroke Epilepsy Following Stroke-Associated Acute Symptomatic Seizures

Abstract

Objective: Post-stroke epilepsy (PSE) is associated with increased morbidity and mortality. Stroke-associated acute symptomatic seizures are an important risk factor: 20.8–34.3% of these patients will go on to develop PSE. Identifying these “high risk” individuals may result in earlier PSE diagnosis, treatment, and avoidance of seizure-related morbidity. This study was to identify predictors of PSE development in patients with stroke-associated acute symptomatic seizures.Participants and Methods: This was a retrospective cohort study of 167 patients with stroke-associated acute symptomatic seizures admitted to the Neurology Department of a tertiary Hospital of China, from 1 May 2006 to 30 January 2020. Both those with primary ischemic stroke and intracerebral hemorrhage were included in the study. Patient demographics, medical history, stroke-associated, and seizure-related variables were evaluated with univariable analysis and multivariable Cox regression analysis. PSE was defined as unprovoked seizures occurring > 7 days post-stroke. Data points were extracted from medical records and supplemented by tele-interview.Results: Of the 167 patients with stroke-associated acute symptomatic seizures, 49 (29.3%) developed PSE. NIHSS score > 14 [hazard ratio (HR) 2.98, 95% CI 1.57–5.67], longer interval from stroke to acute symptomatic seizures (days 4–7 post-stroke) (HR 2.51, 95% CI 1.37–4.59) and multiple acute symptomatic seizures (HR 5.08, 95% CI 2.58–9.99) were independently associated with PSE development. This association remained in the sub-analysis within the ischemic stroke cohort. In the sub-analysis of the hemorrhagic stroke cohort, multilobar involvement (HR 4.80, 95% CI 1.49–15.39) was also independently associated with development of PSE. Further, we developed a nomogram to predict individual risk of developing PSE following stroke-associated acute symptomatic seizures. The nomogram showed a C-index of 0.73.Conclusion: More severe neurofunctional deficits (NIHSS score > 14), longer interval from stroke to acute symptomatic seizures (days 4–7 post-stroke), and multiple acute symptomatic seizures were independently associated with development of PSE in patients with stroke-associated acute symptomatic seizures. This knowledge may increase clinical vigilance for development of PSE, facilitating rapid diagnosis and treatment initiation, and subsequently reduce seizure-related morbidity.

Risk Factors for Postischemic Stroke Epilepsy in Young Adults: A Nationwide Population-Based Study in Taiwan

“…In our Cox regression model, moderate NIHSS scores ( 5 – 9 ) and severe NIHSS scores (≥10) were associated with 1.4-fold and 1.98-fold increases in the risk of PSE, respectively. In previous studies, a high NIHSS score at the time of stroke admission was consistently found to be a risk factor for PSE ( 9 , 15 , 17 ). In our study, the frequency of stroke recurrence was 18.9% during 16-year follow-up, similar to that in previous studies (6%−19%) ( 37 – 39 ), and stroke recurrence was independently associated with the development of PSE.…”

“…Because of distinct characteristics and mechanisms of seizure, most studies set a 7-day interval to categorize early- and late-onset poststroke seizures ( 9 , 11 , 17 , 19 , 27 ). However, this study was unable to identify the exact timing of the first seizure after stroke onset due to the limitation of using the Taiwan NHI research database.…”

“…Therefore, studies have been conducted to identify the risk factors for PSE. Prior studies showed poststroke symptomatic seizures were an important risk factor for PSE ( 17 ). Approximately 30% of stroke patients with acute symptomatic seizures develop PSE ( 17 ).…”

“…Prior studies showed poststroke symptomatic seizures were an important risk factor for PSE ( 17 ). Approximately 30% of stroke patients with acute symptomatic seizures develop PSE ( 17 ). In addition to seizure, the severity of stroke (NIHSS score, coma, and length of hospitalization) ( 9 , 14 , 18 ), localized characteristics of lesions (focal neurological signs, cortical involvement, aphasia and visual field defect) ( 10 , 14 , 19 – 21 ), and stroke recurrence ( 15 ) have been reported to be major predictive factors for PSE.…”

Association between minimally invasive surgery and late seizures in patients with intracerebral hemorrhage: A propensity score matching study

“…According to the definition for acute symptomatic seizures of the International League Against Epilepsy (ILAE), seizures after ICH were classified as early seizures (seizures that occurred within 7 days post-stroke) or late seizures (spontaneous unprovoked seizures that occurred beyond 7 days post-stroke) ( 21 ). Early seizures were extracted from inpatient medical records, while late seizures were identified by medical records and tele-interview based on a standardized questionnaire for screening late seizures ( Supplementary Table S1 ) ( 22 ). The follow- up was conducted by a telephone interview and ended at death or in January 2020 (TJH) and October 2021 (WZH).…”