Seizure outcome and anti-seizure medication use in post-stroke epilepsy: A retrospective cohort study.

Seizure and psychosocial outcomes in patients with DBS for intractable epilepsy.

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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.

Association between metabolic patterns in 18-FDG PET-CT scan and postsurgical seizure outcomes in patients with temporal lobe epilepsy.

Seizure outcomes in children with Sturge-Weber syndrome undergoing epilepsy surgery: An individual participant data meta-analysis

Purpose of ReviewStroke is the most common cause of seizures and epilepsy in older adults. This educational paper aims to give an update on current clinical aspects of diagnosis and treatment of poststroke epilepsy.Recent FindingsRegarding epileptic seizures related to stroke, it is important to distinguish between acute symptomatic seizures and unprovoked seizures as they differ in their risk for seizure recurrence. In fact, after a single unprovoked poststroke seizure, a diagnosis of epilepsy can be made because there is a greater than 60% risk for further seizures. Clinical models that can predict the development of epilepsy after a stroke have been successfully established. However, treatment with anti-seizure medications is advised only after a first unprovoked poststroke seizure, as current treatments are not known to be effective for primary prevention. The management of poststroke epilepsy requires consideration of aspects such as age, drug-drug interactions and secondary vascular prophylaxis, yet evidence for the use of anti-seizure medications specifically in poststroke epilepsy is limited.SummaryThis text reviews the epidemiology and risk factors for poststroke epilepsy, explains the role of EEG and neuroimaging in patients with stroke and seizures and provides an overview on the clinical management of stroke-related acute symptomatic seizures and poststroke epilepsy.

Patients with acute symptomatic seizures (ASyS) after stroke are discharged on antiseizure medications (ASMs) and stay on them for an extended period. We analyzed the current ASM management practice, 6 months, and at the last follow-up after stroke-related ASyS concerns to identify chronic and long-term ASM use predictors. A single-center, retrospective cohort study of adults who underwent continuous EEG monitoring for ASyS concerns after stroke (April 1, 2012 to March 31, 2018) with at least 6 months of follow-up was performed. ASM use beyond 6 months after the initial ASyS concern was defined as "chronic" among patients discharged on them. "Long-term" ASM use at the last follow-up in all patients with ASyS concerns was analyzed. Logistic regression and Cox regression multivariable modeling to analyze predictors of "chronic" and "long-term" ASM use, respectively, was performed. A total of 465 (mean age 61.7 ± 13.3 years and 52% female patients) patients (41.9% ischemic stroke, 36.1% intracerebral hemorrhage, and 21.9% subarachnoid hemorrhage) were included. Of the 179 (38.5%) patients discharged on ASMs, 132 (73.7%; 28.4% of study population) had chronic ASM use, despite 90% not experiencing any seizure (poststroke epilepsy [PSE]) during this time. The independent predictors of chronic ASM use were electrographic ASyS (odds ratio [OR] = 9.27, 95% CI = 2.53-60.4) and female sex (OR = 2.2, 95% CI = 1.02-4.83). After a median 61-month (5.1 years) follow-up, 101 (21.7%) patients in the study population were on long-term ASM use, including 67 (14.4%) who developed PSE. Long-term ASM use was associated with NIH Stroke Scale Score (OR = 1.5, 95% CI = 1.015-1.98), cortical involvement (OR = 1.28, 95% CI = 1.02-1.6), convulsive ASyS (OR = 1.46, 95% CI = 1.02-2.09), epileptiform findings on outpatient EEG (OR = 4.03, 95% CI = 1.28-12.76), and PSE development (OR = 7.06, 95% CI = 3.7-13.4). Chronic ASM use is highly associated with electrographic, rather than convulsive, ASyS. However, long-term ASM use is independently associated with PSE and its risk factors, including convulsive ASyS. With the ubiquity of stroke-related ASyS concerns in routine clinical practice, comparative effectiveness studies to guide ASM management are needed.

Background and ObjectiveStatus 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.MethodsData 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.ResultsOf 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).ConclusionsBased 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 RegistrationThis study was registered at ClinicalTrials.gov (NCT05267405).

ObjectiveWe aim to compare the effect of long-term anti-seizure medication (ASM) monotherapy on the risk of death and new ischemic stroke in patients with post-stroke epilepsy (PSE).Patients and methodsWe identified all hospitalized patients (≥ 20 years) with a primary diagnosis of ischemic or hemorrhagic stroke from 2001 to 2012 using the National Health Insurance Research Database in Taiwan. The PSE cohort were defined as the stroke patients (1) who had no epilepsy and no ASMs use before the index stroke, and (2) who had epilepsy and ASMs use after 14 days from the stroke onset. The patients with PSE receiving ASM monotherapy were enrolled and were categorized into phenytoin, valproic acid, carbamazepine, and new ASM groups. We employed the Cox regression model to estimate the unadjusted and adjusted hazard ratios (HRs) with 95 % confidence intervals (CIs) of death and new ischemic stroke within 5 years across all groups, using the new ASM group as the reference.ResultsOf 6962 patients with PSE using ASM monotherapy, 3917 (56 %) were on phenytoin, 1623 (23 %) on valproic acid, 457 (7 %) on carbamazepine, and 965 (14 %) on new ASMs. After adjusting for confounders, compared with new ASM users, phenytoin users had a higher risk of death in 5 years (HR: 1.64; 95 % CI: 1.06–2.55). On the other hand, all ASM groups showed a similar risk of new ischemic stroke in 5 years.ConclusionsAmong patients with PSE on first-line monotherapy, compared to new ASMs, use of phenytoin was associated with a higher risk of death in 5 years.

Although post-stroke epilepsy (PSE) is a prevalent complication in children, optimal management remains challenging. This study evaluated the impact of different treatment modalities and antiseizure medications (ASM) on the development and management of pediatric PSE following arterial ischemic stroke. We conducted a retrospective cohort analysis over 20 years, examining pediatric patients who experienced seizures during the course of arterial ischemic stroke. Exclusions included neonatal stroke, hemorrhagic stroke, and sinovenous thrombosis. Cut-off point of seven days were accepted as early seizures and PSE. Treatments included acute stroke therapies such as intravenous tissue plasminogen activator, mechanical thrombectomy, anti-edema therapies, and antithrombotic treatments. Medications for seizure control were categorized as acute seizure management agents (benzodiazepines and phenytoin), which are not used for long-term post-stroke epilepsy control, and long-term antiseizure medications (levetiracetam and carbamazepine) for PSE management. Among 153 patients, 99 were male, with a median age of 23 months. PSE was diagnosed in 59.5% of the cohort. Cardiac disorders were the primary etiology (32.7%). Hyperacute treatments and anti-edema therapies showed no significant impact on PSE development. Benzodiazepines and phenytoin also did not affect PSE rates. Levetiracetam was associated with a higher PSE rate (66.7%) compared to carbamazepine (45.1%) (p = 0.010). Carbamazepine demonstrated superior seizure freedom at 6 and 24 months (p = 0.024 and p = 0.014, respectively). Seizure control was achieved in 19.8% of PSE patients through dose titration, with carbamazepine showing higher efficacy (p = 0.037). ASM discontinuation rates were higher with carbamazepine (95.7%) compared to levetiracetam (79.4%). Acute stroke therapies, anti-edema, and antithrombotic treatments did not lower the PSE development. Benzodiazepines and phenytoin were not effective in preventing PSE. Carbamazepine may be more effective than levetiracetam in managing pediatric PSE, providing better seizure control and higher ASM discontinuation rates. Further research is needed to confirm these findings.

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.

Effect of Lacosamide on Interictal Epileptiform Discharges in Pediatric Patients With Newly Diagnosed Focal Epilepsy

Background: People with epilepsy are burdened with consequence of seizures, especially in drug resistant epilepsy. However, patients with poststroke epilepsy (PSE) who were mostly elderly and faced more seizures were affected not only by functional decline but also had no abundant time for antiseizure medication (ASM) trials. Objective: To assess the incidence and factors associated with more than one ASMs in patients with PSE. Methods: A retrospective chart review study was evaluated in 136 patients with a stroke onset following seizure with admission, who fulfilled the poststroke epilepsy diagnosis from January 2016 to June 2023. Then, they were categorized into only one and more than one ASMs groups to analyze. Results: The incidence rate of patients with more than one ASMs in PSE was 89.0 persons and drug resistant PSE was 16.7 persons/1000 person-years. The median time to follow was 30 months and seizure latency was 7 months. The hemorrhagic stroke type was a factor associated with more than one ASMs compared with ischemic stroke (OR, 2.77; 95% CI, 1.23 - 6.23; P = .01). There was a multicollinearity effect in hemorrhagic stroke with cranial surgery during stroke events and underlying atrial fibrillation. Conclusions: More than one ASMs in patients with PSE were applied in neurological practices per the incidence. Moreover, the hemorrhagic stroke was found to be associated with more than one ASMs.

Efficacy and safety of antiseizure medication in post-stroke epilepsy