中风后癫痫59例分析

对641例中风患者追踪观察1～3年,结果59例出现癫痫发作,中风后癫痫发生率为9.20％;脑出血与脑梗塞癫痫发生率间比较无已著差异(P>0.05);皮层损害者癫痫发生率显著高于皮层下损害者(P<0.01);脑出血继发癫痫发作多属早期发作(8/11),而脑梗塞多属迟发性癫痫发作(40/48)(P<0.01);早期癫痫发作需长期服抗癫痫药控制者显著低于迟发性癫痫发作(P<0.01)。提示:病损波及皮层是重要的致痫因素;早期发作与迟发性癫痫发作的发病机理不同,故表现出治疗与转归不同;迟发性癫痫尤其病灶波及皮层者长期规则服抗癫痫药是必要的。     

Risk of epilepsy in long-term survivors of surgery for aneurysmal subarachnoid hemorrhage: a population-based study in Iceland

PURPOSE: Epilepsy is known to result from aneurysmal subarachnoid hemorrhage (SAH). There are no population-based estimates of the absolute risk or the duration for which this risk is elevated. We have conducted a population-based study in Iceland of the risk of epilepsy after a ruptured cerebral aneurysm to address these questions. METHODS: The index patients are all of the patients who presented with SAH caused by ruptured cerebral aneurysm in Iceland during an 11-year period (1958 to 1968) and survived more than 6 months. We determined the number of index patients who developed epilepsy. The observed number of cases of epilepsy was compared with that expected based on the incidence of epilepsy in Iceland. RESULTS: There were 44 index patients; 11 (25%) developed epilepsy, all within 4 years of the insult. Seven (70%) of 10 patients with acute symptomatic seizures (defined as seizures during the first 2 weeks after the hemorrhage) developed epilepsy (relative risk, 7.0; 95% confidence interval, 2.3-21.6). Epilepsy was more frequent in patients with severe neurological residua (48%) compared with patients without (20%) (relative risk, 2.5; 95% confidence interval, 0.9-6.3). CONCLUSIONS: The risk for epilepsy among survivors of SAH caused by ruptured cerebral aneurysm is substantially increased. Both acute symptomatic seizure and persistent neurological impairment are associated with a further increase in the risk of epilepsy.     

Epilepsy in children with delayed presentation of perinatal stroke

A subgroup of children with perinatal stroke do not present clinically until after the perinatal period. Detailed epilepsy outcomes in these children have not been well studied. A retrospective cohort study of 45 children with delayed presentation of perinatal stroke identified by review of pediatric stroke clinic records, physician referral, and International Classification of Diseases, Ninth edition, code searches of hospital records, was performed at a tertiary pediatric hospital in Indianapolis, Indiana. A modified version of the Engel scale was used to grade epilepsy outcomes. The chi(2) test, Fisher's exact test, and relative risks were calculated to examine the association of epilepsy at time of last follow-up with initial presentation with seizures, infantile spasms, radiographic findings, and initial abnormal electroencephalogram (EEG). These tests were also used to examine the association of epilepsy with cognitive or motor disability and the association of initial abnormal EEG with motor disability. Patients presented with hemiparesis (40; 89%), seizures (4; 9%), or headaches (1; 2%). All had unilateral infarcts on cranial imaging. Four children (9%) had infantile spasms, 2 at presentation and 2 later. Nineteen children received at least 1 EEG for suspicious spells or frank seizures; initial EEG was abnormal in 16 patients (84%). At last follow-up, 17 patients (38%) had epilepsy, which was severe in 4 (24% of those with epilepsy). Initial presentation with seizures (relative risk = 3.2; 95% confidence interval, 2.0-4.9) and infantile spasms (relative risk = 3.2; confidence interval, 2.0-4.9) were associated with epilepsy at last follow-up. Infantile spasms were also associated with moderate-to-severe epilepsy at last follow-up (relative risk = 10.3; confidence interval, 1.9-54.4). Epilepsy at last follow-up was associated with cognitive disability (P = .05). Initial abnormal EEG was not associated with cerebral palsy (P = .30). Epilepsy is frequent in children with delayed presentation of perinatal stroke and is associated with initial presentation with seizures and infantile spasms at any point in time. Cognitive disability often accompanies epilepsy in these children.     

Disparities in diagnosis of cerebral amyloid angiopathy based on hospital characteristics

Cerebral amyloid angiopathy (CAA) categorized as a cerebral small vessel disease can cause lobar intracerebral hemorrhage (ICH), convexity subarachnoid hemorrhage (SAH) and ischemic stroke (IS). The purpose of this study was to evaluate the differences in the diagnosis of CAA based on hospital characteristics and to assess the discharge outcomes of patients with CAA admitted for IS, ICH and SAH. Adult patients admitted with secondary diagnosis of CAA were identified in National Inpatient Sample in 2016 and 2017. Multivariable logistic regression analysis was performed to evaluate outcomes. A total of 16,040 patients had a secondary diagnosis of CAA. Among CAA patients, 1810 (11.3%) patients were admitted for IS, 4765 (29.7%) for ICH and 490 (3.1%) for SAH. Diagnosis of CAA was five-fold higher among patients admitted to urban teaching hospitals (aOR = 5.4;95% CI = 4.1–7.2) compared to rural hospitals and two-fold higher in large bed size hospitals (aOR = 2.3;95% CI = 2.0–2.7) compared to small bed size hospitals. Compared to non-CAA group, patients with history of CAA had lower odds of in-hospital mortality among patients admitted for ICH (10% vs 23%, aOR = 0.35; 95%CI = 0.27–0.44) and SAH (6% vs 19%, aOR = 0.24; 95%CI = 0.10–0.55); and higher odds of discharge to home among patients admitted for ICH (17% vs 18%, aOR = 1.27; 95%CI = 1.05–1.53). CAA diagnosis is less common in rural and small bed size hospitals compared to urban and large bedside hospitals, respectively. Patients with CAA admitted for ICH have better discharge outcomes compared to non-CAA patients admitted for ICH.     

Epileptic seizures in intracerebral haemorrhage.

Among 1402 patients with intracerebral haemorrhage (ICH), seizures occurred in 64 (4.6%) and epilepsy in 35 (2.5%). Seizure was the first manifestation of ICH in 19 patients (30%). Status epilepticus occurred in 11 patients (17%) and it was the initial presentation of ICH in six (9%). The majority had simple partial seizures that were predominantly focal and motor. There were 38 patients with early seizure and 26 patients with late seizure. Ninety per cent of seizures occurred within one year after ICH. Eleven patients (29%) with early seizure developed epilepsy, whereas 24 patients (93%) with late seizure developed recurrent seizures. The incidence of seizure was 32% for lobar haematoma, 2% respectively for putaminal, thalamic and pontine haemorrhages and 1% for cerebellar haemorrhage. Twenty-six (62%) out of 42 patients with lobar haematomas developed epilepsy. Thirteen patients (34%) with early seizure died within three months after the onset of seizures whereas three patients (12%) with late seizure died within the same period. The majority of patients who died had deep-seated haematomas.     

蛛网膜下腔出血继发症状性癫痫的发生率、危险因素及院内结局：来自中国卒中联盟登记数据库的分析

目的调查蛛网膜下腔出血(subarachnoid hemorrhage,SAH)患者继发症状性癫痫的发生率、相关危险因素及其与院内结局的关系。方法本研究数据来源于中国卒中联盟(China Stoke Center Alliance,CSCA)登记数据库2015年8月1日-2019年7月31日入组的SAH患者。症状性癫痫限定为住院期间发作。依据是否出现继发症状性癫痫,将研究对象分为SAH继发癫痫组和无继发癫痫组,比较组间的人口学特征、入院GCS评分、血管危险因素、手术以及医院级别和地区的差异。采用多因素Logistic回归,分析SAH继发癫痫的危险因素,以及SAH继发癫痫与院内死亡、缺血性卒中、脑出血及肺炎的相关性。结果本研究纳入11 210例SAH患者,女性6623例(59.1%),平均年龄60.0±12.9岁,入院GCS评分的中位数为15分。总计228例(2.0%)继发症状性癫痫。年龄(OR 0.92,95%CI 0.87～0.97)、既往卒中/TIA(OR 1.61,95%CI 1.20～2.17)、颈动脉狭窄(OR 3.17,95%CI 1.27～10.85)、心房颤动(OR 2.64,95%CI 1.12～6.24)、脂代谢紊乱(OR 1.79,95%CI 1.03～3.13)和脑室外分流术(OR 2.30,95%CI 1.31～4.02)是SAH继发症状性癫痫的独立影响因素。SAH继发症状性癫痫可能与更高的院内死亡(OR 1.71,95%CI 0.96～3.05)、缺血性卒中(OR 4.21,95%CI 2.70～6.56)、脑出血(OR 3.87,95%CI 2.81～5.33)及肺炎(OR 2.96,95%CI 2.26～3.86)事件风险相关。结论症状性癫痫是SAH患者较为常见的神经系统并发症,低龄、既往卒中/TIA、颈动脉狭窄、心房颤动、脂代谢紊乱以及脑室外分流术是SAH继发症状性癫痫的独立危险因素。SAH继发症状性癫痫增加院内死亡、缺血性卒中、脑出血以及肺炎的风险。     

Surgical hematoma evacuation of cortical intracerebral hemorrhage ≥10 ml reduces risk of subsequent epilepsy by more than 70%: A retrospective monocenter study

Aim

The aim of this study was to re-evaluate risk factors for post-ICH epilepsy (PICHE) and examine the impact of surgical hematoma evacuation on epilepsy development after ICH.

Background and purpose

Epilepsy is a common complication after intracerebral hemorrhage (ICH). Information on risk factors is still scarce and the role of ICH evacuation remains uncertain.

Methods

We retrospectively included patients with spontaneous ICH treated in our hospital in 2006–2019. Patients' medical records were analyzed. In addition, mailed questionnaires and telephone interviews were used to complete the dataset. Uni- and multivariable hazard ratios (HRs) were applied to investigate risk factors for PICHE and the impact of surgical ICH evacuation.

Results

Among 587 ICH patients available for analyses, 139 (23.7%) developed PICHE (mean follow-up 1795 ± 1378 days). The median time of epilepsy onset was 7 months after ICH (range 1–132 months). Risk factors associated with PICHE were cortical hemorrhage (multivariable HR 1.65 [95% CI 1.14–2.37]; p = 0.008), ICH volume > 10 ml (multivariable HR 1.91 [95% CI 1.33–2.73]; p < 0.001) and acute symptomatic seizures (multivariable HR 1.81 [95% CI 1.20–2.75]; p = 0.005). Patients with cortical ICH > 10 ml who underwent surgical hematoma evacuation were less likely to develop epilepsy than those with conservative treatment alone (multivariable HR 0.26 [95% CI 0.08–0.84]; p = 0.025).

Conclusions

Post-ICH epilepsy is frequent and predicted by large cortical ICH and acute symptomatic seizures. Hematoma evacuation reduced the risk of PICHE by more than 70% in patients with large cortical ICH. This finding could be considered in the clinical decision making on the acute treatment of ICH.     

Early seizures following intracerebral hemorrhage: implications for therapy

Seizures occurred in 19 of 112 patients (17%) with nontraumatic, supratentorial intracerebral hemorrhage (ICH). All seizures occurred at ICH onset; patients without seizures at hemorrhage onset remained seizure-free until the last recorded follow-up. Seizures were significantly associated with extension of blood into the cerebral cortex. We found no association between seizures and hemorrhage size or the presence of subarachnoid or intraventricular blood. These data suggest that (1) seizures, in ICH, occur at hemorrhage onset, (2) patients without seizures at hemorrhage onset are at very low risk for subsequent seizures during their hospitalization, (3) hemorrhage involving the cerebral cortex, regardless of site of origin, predisposes to seizures, and (4) the prophylactic use of anticonvulsants in the acute management of these patients appears unwarranted, especially in patients without cortical extension.