Early seizures in acute stroke

Early seizures in acute stroke

Chraa Mohamed^1,&, Najib Kissani¹

¹Neurology Department, Mohamed VI University Hospital, Marrakesh, Morocco

^&Corresponding author
Chraa Mohamed, Neurology Department, Mohamed VI University Hospital, Marrakesh, Morocco

Seizures are common during the early phase after stroke and have been reported to occur with a frequency of 2.5% to 5.7% within 7 to 14 days (the window where seizures are classified as early ones) of the acute episode [1]. In another hand stroke is the most common cause of epileptic seizures in the elderly population [2]. The effect of ES on prognosis is not known. If ES worsens prognosis, the prophylactic use of anticonvulsants in patients at risk is recommended [3]. Cortical involvement, stroke severity, multiple CT-scan lesions, hemorrhagic stroke, and are the most reported predictive factors [4, 5]. The aim of this study was to determine to rate, the predictor factors as well as the outcomes of ES in ischemic stroke.

A total of 352 consecutive patients with first-ever stroke, admitted to the neurology department, Mohammed VI universitary hospital in Marrakesh, from January 2004 to December 2009, were included in this retrospective study. Early seizures were defined as seizures occurring within 7 days from acute stroke according to the international league against epilepsy guidelines (1993). Patients with history of epilepsy, transient ischemic attack, subarachnoid hemorrhage were excluded, as well as those with cerebral vein thrombosis. The assessment of stroke was performed by a senior neurologist. All patients performed a CT scan or MRI in some cases. Information extracted from the folders included age, sex, occupation, time for initial admission, clinical features, presence or absence of risk factors such as hypertension, diabetes mellitus, history of cigarette smoking and a history of stroke or epilepsy in the patient. Stroke severity was evaluated at admission using the National Institute of Health Stroke Scale (NIHSS). All analyses were performed with the SPSS (Property of Caddi Ayad university) and Statistical significance was set at p < 0.05.

A total of 352 patients with first ever ischemic stroke were included in this study. ES developed in 47 (13%) cases. The mean age was 60.5 ± 10.5 years with only 3 patients under the age of 45. Twenty-eight of the patients with ES (60%) were female and nineteen (40%) were male. The ES were simple in 39 cases (83%), and 8 patients had a status epilepticus. Risk factors of ischemic stroke are summarised in Table 1, it shows no significant differences between the groups of patients with and without ES. In a univariate analysis, large ischemic stroke, cortical involvement as well as hemorrhagic transformation were all more frequent in patients with ES than those without it (58.7% vs 37.4%, 68% vs 36% and 15% vs 7% respectively), see Table 1. The univariate analysis also showed that the initial stroke severity on admission was significantly higher in patients with ES than in patients without ES (p = 0.04). No significant differences were observed in terms of the major aetiologies of stroke (cardioembolic stroke and atherosclerosis) between the two groups. Finally the outcome was influenced by the ES in terms of mortality (47% in ES patients' vs 26% in the other group) but not in terms of physical handicap (19% vs 18%).

The pathophysiology of seizures after stroke is not completely understood but several mechanisms are hypothesized: cellular biochemical dysfunction with membrane instability of injured cells; transient excitoxic neurotransmitter release, such as glutamate, secondary to hypoxia; free radical damage, transient depolarizations of the ischemic penumbra with a resulting electrical irritable tissue [6, 7]. In our study, there was no relationship between ES and age, gender, ischemic heart disease, or hypertension, but a relationship was found between ES and initial stroke severity, these results are consistent with the conclusions of previous publications [4]. Some previous studies have indicated a relationship between infarct size and ES [8], results obtained in our study are in favor of the existence of such a relationship. In another hand we found a strong association between cortical involvement and ES in stroke, this observation has been reported in some studies [9- 12], but not in others [13], this may be explained by acute cortical irritability, which may not undergo the same physiopathology as vascular epilepsy. We identified hemorrhagic transformation as associated with higher risk of ES in patient with stroke; these results are consistent with previous studies suggestions [13]. No significant differences were established between patients with and without ES in term of the underlying etiologies especially cardioembolic stroke which is reported to be a predictor for ES development [14, 15], which join the results of others similar studies [10, 11, 13]. The influence of ES on prognosis of stroke is controversial, in our study we found that ES were associated with higher risk of mortality but not of disability, our results join others conclusions in some studies [12], but not in others [13].

About 13 % of patient with stroke developed ES in our study. The predictive factors for ES occurrence in stroke were its clinical severity, cortical involvement and hemorrhagic transformation. Finally, ES was associated with high risk of mortality.

The authors declare no competing interest.

All the authors have contributed to this study in ways that comply to ICMJE authorship criteria. All the authors have read and approved the final version of the manuscript.

Table 1: clinical features in patients with and without early seizures

1. Kilpatrick CJ, Davis SM, Tress BM, Rossiter SC, Hopper JL, Vandendriesen ML. Epileptic seizures in acute stroke. Arch Neurol. 1990 Feb;47(2):157-60. PubMed | Google Scholar


2. Louis S, McDowell F. Epileptic seizures in nonembolic cerebral infarction. Arch Neurol. 1967 Oct;17(4):414-8. PubMed | Google Scholar


3. Lo YK, Yiu CH, Hu HH, Su MS, Laeuchli SC. Frequency and characteristics of early seizures in Chinese acute stroke. Acta Neurol Scand. 1994 Aug;90(2):83-5. PubMed | Google Scholar


4. Leone M,A, et al. Risk factors for a first epileptic seizure after stroke: A case control study.Journal of the Neurological Sciences. 2009 Feb 15;277(1-2):138-42. PubMed | Google Scholar


5. Camilo O, Goldstein LB. Seizures and epilepsy after ischemic stroke. Stroke. 2004 Jul;35(7):1769-75. PubMed | Google Scholar


6. Herman ST. Epilepsy after brain insult. Neurology. 2002 Nov 12;59(9 Suppl 5):S21-6. PubMed | Google Scholar


7. Heuts-van Raak L, Lodder J, Kessels F. Late seizures following a first symptomatic brain infarct are related to large infarcts involving the posterior area around the lateral sulcus. Seizure. 1996 Sep;5(3):185-94. PubMed | Google Scholar


8. Gupta SR, Naheedy MH, Elias D, et al. Post infarction seizures: A clinical study. Stroke. 1988 Dec;19(12):1477-81. PubMed | Google Scholar


9. Black SE, Norris JW, Hachinski VC. Post-stroke seizures (Abstract) . Stroke. 1983;14:134. PubMed | Google Scholar


10. Lancman ME, Golimstock A, Norscini J, Granillo R. Risk factors for developing seizures after stroke. Epilepsia. 1993 Jan-Feb;34(1):141-3. PubMed | Google Scholar


11. Jakob Reith, MD, Henrik Stig Jorgensen, MD, PhD, Hirofumi Nakayama, MD, PhD, Seizures in Acute Stroke: Predictors and Prognostic Significance. Stroke. 1997 Aug; 28 (8):1585-9. Google Scholar


12. Drea A, Pacioroni,M . Early seizures in patients with ischemic stroke. Vascular health and risk management. 2008;4(3):715-20. PubMed | Google Scholar


13. Giroud M, Gras P, Fayolle H, Andre N, Soichot P, Dumas R. Early seizures after acute stroke: a study of 1,640 cases. Epilepsia. 1994 Sep-Oct;35(5):959-64. PubMed | Google Scholar


14. Lesser RP, Luders H, Dinner DS, et al. Epileptic seizure due tovthrombotic and embolic cardiovascular disease in older patients. Neurology. 1985;26(6): 622-630. PubMed | Google Scholar


15. Kittner SJ, Sharkness CM, Price TR, et al. Infarcts with a cardiac source of embolism in the NINCDS Stroke Data Bank: historical features. Neurology. 1990 Feb;40(2):281-4. PubMed | Google Scholar