Influence of pre-existing dementia on the risk of post-stroke epileptic seizures

BACKGROUND: Seizures occur in 10% of stroke patients, but their predictors have not been clearly identified. Pre-existing dementia is present in 12-16% of stroke patients and, at the community level, patients with dementia have increased risk of seizures. However, the question of whether pre-existing dementia is associated with a higher risk of seizures after stroke has never been studied. AIM: To evaluate whether pre-existing dementia is associated with an increased risk of seizures after stroke. METHODS: The study was conducted on 202 consecutive stroke patients recruited to the Lille stroke/dementia study (97 men; median age, 75 years; range, 42-100). Pre-stroke cognitive functions were evaluated using the Informant Questionnaire on Cognitive Decline in the Elderly, with a cutoff value of 104 for the diagnosis of dementia. Seizures were defined as early seizures when occurring within seven days of stroke onset, and as late seizures when occurring more than seven days after stroke. RESULTS: Of 202 patients, 33 (16.3%) met the criteria for pre-existing dementia, and 11 (5.4%) developed early seizures. During 289 person-years of follow up, 14 patients developed late seizures, resulting in an incidence rate of 4.8 new cases/100 person-years. Pre-existing dementia was not associated with the occurrence of early seizures, but was independently associated with the occurrence of late seizures (adjusted odds ratio, 4.66; 95% confidence interval, 1.34 to 16.21). CONCLUSION: Stroke patients with pre-existing dementia have an increased risk of late seizures. Any factor increasing the risk of seizures (drugs, metabolic changes) should be avoided in these patients.     

Early seizures after acute stroke. Risk of late seizures.

The prognosis of early seizures after stroke is controversial. We assessed the incidence of late seizures in 31 patients with early seizures complicating acute stroke and compared this with the incidence of late seizures in 31 matched patients with stroke without early seizures. Ten (32%) of 31 patients with early seizures had late seizures during a mean follow-up period of 26 months. Only three (10%) of 31 patients without early seizures had late seizures during the follow-up period of 28 months, a significantly lower incidence than in patients with early seizures. The risk of seizure recurrence in patients with early seizures did not correlate with stroke type or lesion size as imaged on the computed tomographic scan. We conclude that early seizures are not benign and are associated with a significant risk of seizure recurrence.     

卒中后癫发作复发影响因素的研究

目的 旨在通过回顾性研究卒中后癫发作及其复发情况,并分析其可能的影响因素,为临床治疗提供参考。
方法 将122例卒中后癫发作患者分组：单次癫发作（随访至少6个月只出现1次癫发作）组26例,癫发作复发（卒中后出现≥2次癫发作）组96例。观察患者的基础情况、卒中的危险因素、卒中的类型、癫发作的类型、发作频次、治疗等情况与复发的关系。
结果 性别、年龄、卒中的类型、卒中危险因素、卒中的部位以及脑电图改变在两组间无差异。晚发性癫发作、部分性癫发作以及接受治疗情况在组间有统计学差异（P<0.05～0.01）。Logistic多元回归提示晚发性癫发作是癫发作复发的危险因素之一,比值比为3.628;95%置信区间为1.237～10.638,部分性癫发作患者较全面性癫发作患者更易复发,比值比为10.50,95%置信区间为1.35～81.97。
结论 晚发性癫发作是癫发作复发的影响因素之一,部分性癫发作患者倾向于复发。     

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.     

Epileptic seizures in thrombotic stroke

Summary Epileptic seizures due to thrombotic cerebral infarction were studied in 118 patients. The occurrence of seizures had a bimodal distribution with one peak period within 2 weeks and another peak period from 6 to 12 months after stroke. Four patients had seizures preceding stroke, while 23 patients without a history of previous stroke had silent infarct on the CT scan. Fifteen patients (13%) had status epilepticus. Simple partial seizures occurred in 56% of patients, complex partial seizures in 24% and generalized tonic-clonic seizures in 4%. Epilepsy developed in 35% of patients with early seizures and in 90% of patients with late seizures.     

卒中后癫发作时间分布及影响因素的研究

目的 分析卒中后癫发作时间分布特点,并对其影响因素进行研究。 方法 将122例卒中后癫发作患者分为早发性癫发作组（卒中后2周内出现癫发作）60例;晚发性癫发作组（卒中2周后出现癫发作）62例。进行单因素及多因素分析,研究患者的基础情况、卒中的危险因素、卒中的类型、癫发作的类型、发作频次、治疗等情况与早发及晚发的关系。 结果 性别、年龄、卒中危险因素以及脑电图改变在两组间无差异。缺血性卒中出血转化是卒中后癫发作早发的危险因素;早发性癫发作倾向于表现为全面性强直阵挛发作,晚发性癫发作倾向于表现为部分性发作;颞叶病变是卒中后癫发作晚发的危险因素;晚发性癫发作倾向于复发。早发性癫发作患者接受短期治疗的比例较高,晚发性癫发作患者接受长期治疗的比例较高。Logistic多元回归提示糖尿病是卒中后癫发作早发的危险因素（OR＝2.664,95%CI=1.143～6.210,P=0.259）。 结论 糖尿病和缺血性卒中出血转化为卒中后癫发作早发的危险因素;而颞叶病变是卒中后癫痫发作晚发的危险因素,且晚发性癫发作更倾向于复发。     

老年人卒中后痫样发作现象的调查研究

This prospective study sought to investigate the clinical,radiological and electroencephalographic(EEG) characteristics of seizures in elderly stroke patients,and their outcomes.Over a 2-year study period,158 consecutive elderly patients with stroke were examined and followed up.Of these patients,32(20%) developed seizures,primarily related to stroke,within a follow up period between 5 months and 2 years.Of these 32 cases,20 experienced infarctions,and 12 experienced hemorrhages.Involvement of cortical regions was detected in most of the patients exhibiting seizures.In these patients,44% of the lesions involved cortical areas exclusively or in addition to subcortical areas observed on computed tomography(CT) images.Twenty-five patients(78%) developed early seizures(within 2 weeks after stroke),and half exhibited immediate post-stroke seizures.None of the patients exhibiting early onset seizures developed recurrent seizures or epilepsy,while 57% of late onset seizures(four cases) developed epilepsy.No specific EEG patterns were apparent in those who later developed epilepsy.Overall,early onset seizures after stroke were found to be relatively common,and did not affect outcome.Late onset seizures were less common,but were associated with chronic epilepsy.     

Epileptic crisis during and after cerebrovascular diseases. A clinical analysis of 78 cases]

Seventy-eight patients with post-stroke seizures were studied retrospectively to determine the clinical, EEG and CT features of these seizures and their prognosis. There were 57 cerebral infarctions and 21 hemorrhages. Twenty-eight (36%) initial seizures occurred within one month after the stroke (0-24 hours in 19 cases) and were classified as early-onset seizures. Fifty (64%) initial seizures occurred more than 3 months after the stroke (3-12 months in 33 cases) and were classified as late-onset seizures. Compared with a population of 1938 strokes admitted during the same period, the proportion of patients with alcohol abuse, infarction in the anterior cerebral artery territory, watershed infarcts and lobar haemorrhages was significantly greater in our series. The proportion did not vary with the nature of the stroke (infarction or hemorrhage), except for early onset seizures in which the proportion of hemorrhages was significantly greater. Nor did it vary with the cause of hemispheric infarctions (cardioembolism or atherothrombosis or others). Ninety-five percent of the lesions affected the cerebral cortex or the subcortical white matter or both. Of all 78 initial seizures, 64% were partial motor (simple or secondarily generalized); 32% were primarily generalized, and 4% were partial not motor; status epilepticus was seen in 14% of the cases. An initial EEG, performed in 76 patients was normal in 7. Among the remaining 69 patients EEG showed focal or diffuse slowing down in 63% and epileptic features in 37% (including 10 cases of PLEDs). Early post-seizure EEG and repeated recordings significantly increased the specificity of EEG.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical characteristics of early and late recurrent ischaemic stroke

Background and purposeThe aim of the study was to search for differences between clinical characteristics of recurrent ischaemic stroke which occurred within the fifth year after the first event or later, and early recurrence, i.e. within the first year after first-ever ischaemic stroke. We also tried to determine prognostic factors of late recurrent ischaemic episodes.Material and methodsThe patients were divided into two groups: group I comprised 124 individuals with recurrence within the first year, and group II ? 98 individuals in whom the recurrent episode appeared within the fifth year or later.ResultsA significantly higher percentage of patients in group I demonstrated evident stenosis (70% or more) of internal carotid artery ipsilateral to stroke (p = 0.023). In this group more cardioembolic strokes were found compared to group II, while in the latter, predominantly lacunar strokes appeared (p = 0.046 and 0.0002, respectively). Group II patients significantly more frequently reported acetylsalicylic acid application, including systematic drug use (p = 0.001). No evident differences were found between groups considering other important non-modifiable and modifiable risk factors of stroke.ConclusionsSmall differences between risk factors of ischaemic stroke profiles in patients with early and late recurrent episodes do not allow us to distinguish unequivocally a group of patients with better prognosis regarding the time of recurrent stroke. Use of antiplatelet drugs, either systematic or non-systematic, and lacunar stroke are independent, positive prognostic factors of delay of potential recurrent stroke.     

脑卒中后癫痫50例临床研究

目的探讨脑卒中后癫痫的临床特点，癫痫对脑卒中恢复期神经功能康复的影响。方法50例脑卒中后继发癫痫患者进行发作部位、类型、治疗时间及效果等分析，并按病情轻、中、重三组进行功能康复评分。结果脑卒中后癫痫发生率5．1%（50／980），其中早发癫痫72％（36／50），迟发癫痫28％（14／50）。皮层病灶继发癫痫72％（36／50），皮层下病灶继发癫痫占28％（14／50）。早发癫痫中全身发作27例．部分性发作9例，迟发癫痫中全身发作4例，部分性发作10例。癫痫组神经功能缺损评分均差于对照绀组（P〈0．05），结论脑卒中后癫痫皮层病灶多见，早发癫痫以全身发作为主，迟发癫痫以部分发作为主。脑卒中合并癫痫患者的治疗效果差于对照组，抗癫痫治疗有利于神经功能康复。     

Atrial fibrillation as a predictive factor for severe stroke and early death in 15,831 patients with acute ischaemic stroke

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia and a major risk factor for stroke. AIMS: To assess whether AF in patients with acute ischaemic stroke is associated with severe stroke and early death. MATERIALS/ METHODS: Patients with acute ischaemic stroke (15,831) who were registered in the Japan Multicenter Stroke Investigators' Collaboration registry were analysed. The AF group comprised 3335 (21.1%) patients (median age, 75 years) and the non-AF group comprised 12,496 (78.9%) patients (median age, 70 years). The association between AF and severe stroke and early death was investigated by means of multivariate logistic regression analysis. RESULTS: The admission National Institutes of Health Stroke Scale (NIHSS) score of the AF group was higher than that of the non-AF group (median, 12 v 5; p < 0.0001). Multivariate logistic regression analyses found that female sex, advanced age, AF, and a history of stroke were independent factors associated with severe stroke (NIHSS score, > or = 11). The mortality rate within 28 days after admission was 11.3% in the AF group and 3.4% in the non-AF group (p < 0.0001). Multivariate logistic regression analyses identified older age, AF, and NIHSS score at admission as independent factors associated with early death. CONCLUSION: AF was a predictive factor for severe stroke and early death in acute ischaemic stroke. Careful cardiac evaluation and appropriate treatment are needed to improve outcome in patients with acute stroke and AF.     

SPECT-DTPA as a tool for evaluating the blood–brain barrier in post-stroke seizures

Stroke is a well-known cause for seizures in the adult population. Research in animal models indicates that abnormalities in the blood-brain barrier (BBB) permeability can play a role in the development of spontaneous seizures or status epilepticus. The integrity of the BBB was investigated in patients with late post-stroke seizures by performing DTPA-SPECT studies to evaluate the correlation of BBB dysfunction in late post-stroke seizures. All patients with late-onset post-cortical stroke seizures hospitalized during 2009-2010 underwent a brain DTPA-SPECT within 72?h of the first seizure and were compared to a control group of stroke patients without seizures. Twenty-eight patients were included in the study. Twelve out of 14 (85.7%) in the group of seizure post-stroke patients had a positive brain DTPA-SPECT showing disruption of the BBB in the region of the stroke respective to four patients out of 14 (28.6%) in the control group of stroke patients without seizures (p?=?0.001). The results of this study suggest that there is a correlation between late post-stroke seizures and BBB disruption, as revealed by DTPA-SPECT examination. Perhaps, this finding could lead to the hypothesis that the BBB disruption can predict developing seizures in patients with cortical stroke.     

Seizures in childhood ischemic stroke in Taiwan

In this retrospective study, we collected clinical and radiographic data on children (age range, 1 month to 18 years) with symptoms and radiographic confirmation of seizure after ischemic stroke for the period of January 1996 to July 2006. Thirty-nine out of 94 children with ischemic stroke had poststroke seizures. Thirty-three out of 39 children with poststroke seizures had new onset seizures but only data of 28 were available. Infection was the most common etiology in the early poststroke seizure group (52.4%) but not in the late poststroke seizure group (0%). Infarction involving arterial ischemic stroke of anterior circulation were the most common in both the early poststroke seizure (61.9%) and the late poststroke seizure group (57.1%). Epilepsy was the most common sequelae in both the early poststroke seizure (38.1%) and late poststroke seizure group (100%). Children who had initial focal neurological sign (100% vs. 38.1%; P=0.007) or the focal cortical dysfunction on EEG (85.7% vs. 33.3%; P=0.029) were prone to develop late poststroke seizures. Late poststroke seizures had a high risk of developing poststroke epilepsy (100% vs. 38.1%; P=0.007). We conclude that seizures commonly occur in childhood ischemic stroke. Most poststroke seizures developed at an early stage. Infection was the most common etiology that caused early poststroke seizures in childhood ischemic stroke. Initial focal neurological signs and focal cortical dysfunction on EEG are risk factors for developing epilepsy. Poststroke seizures did not affect mortality, but there was a significant difference in normal outcome and epilepsy between those with or without poststroke seizures.     

Systematic prolonged video-electroencephalograms identify electrographic seizures in 5% of acute stroke patients with aphasia

In stroke units, diagnosing seizures may be difficult, especially in aphasic patients. We discuss herein our systematic 4-hour video EEG monitoring of 61 patients with aphasia within the first 72 hours after the onset of ischaemic stroke. Five electrographic seizures were identified in 3 patients, with no clinical signs apparent on the video and no symptoms reported by patients. We did not record status epilepticus nor generalized seizure. Comparative analyses disclosed a higher risk of early seizures in patients with haemorrhagic transformation. Video EEG monitoring detected electrographic seizures in 5% of stroke patients with aphasia. This monitoring could be useful for selected patients, especially those with haemorrhagic transformation.     

Risk Factors for Developing Seizures After a Stroke

Summary: We evaluated development of seizures in 219 consecutive patients who had ischemic or hemorrhagic stroke. Subjects with transitory ischemic attacks, sub-arachnoid, subdural, and epidural hemorrhages or those with previous history of epilepsy were excluded. Mean follow-up time was 11.5 months (range 1–72 months). Twenty-two of 219 stroke patients (10.04%) had seizures. Twelve (54.55%) were of early onset (<1 month after the stroke), and 10 (45.45%) were of late onset. No statistically significant differences were evident between the early- and late-onset seizure group in comparisons of type of stroke, localization, and size of the lesion. Six of 22 patients (27%) had seizure recurrence. Seizures developed in (a) 13 of 183 patients with ischemic stroke (7.1%) and 9 of 36 patients with hemorrhagic stroke (25%) (p = 0.01); (b) 16 of 93 patients with cortical lesions (17%) and 6 of 126 patients with subcortical lesions (4.7%) (p = 0.01); and (c) 14 of 66 patients with a lesion comprising more than one lobe (21.2%) and 8 of 153 patients with a lesion comprising less than one lobe (5.2%) (p < 0.01). We conclude that patients with hemorrhagic stroke, cortical lesions, and lesions involving more than one lobe are at higher risk of developing seizures.     

The difference among patients with acute ischemia stroke and with reversed flow in the ophthalmic artery and the ones with a correct direction of the flow]

METHOD: Fifty-four patients with acute ischaemic stroke (AIS) and with reversed flow direction in the ophthalmic artery (OA) were compared prospectively with patients with normal flow in that artery. Age, sex, presence of atrial fibrillation (AF) and ischaemic heart disease, the course in the acute period within 30 days after stroke onset were analysed. On the first day the following examinations were performed in all patients: routine laboratory investigations, X-ray, ECG and Doppler and USG examinations of the extracranial arteries. In some cases CT of the head was obtained. The condition of the patients was assessed by Rankin scale on the first and 30-th days after stroke onset. Improvement was accepted if on the 30-th day the score was 1 point better than on the first assessment. RESULTS: The mean age in the group with reversed blood flow in OA was 60.7 years, and in the group with normal flow it was 69 years (p < 0.0001). The male/female ratio was statistically significantly different in these groups (p = 0.01): in the younger group with reversed flow males accounted for 76% and in the older group with normal flow--52.5%. AF in the younger group was present in a low proportion of cases (3.7%) but in the older group it was 21.3%, the difference was statistically significant (p = 0.005). No significant difference was found in the presence of ischaemic heart disease. In the patients scoring 4 and 5 in Rankin scale in the first assessment no worsening was noted in the group with reversed blood flow, while in the other group 24% of the patients were worse or died (statistically significant difference, p = 0.004). The course of mild and medium severe stroke within 30 days was similar in both groups. CONCLUSIONS: Patients with AJS and reversed flow in OA-differed from those with normal flow in OA, they were younger, more often were males. AF was present in isolated cases and the course of major stroke was milder.     

Early carotid surgery in acute stroke: a multicentre randomised pilot study

BACKGROUND: Standard practice has been to delay carotid endarterectomy (CEA) for 2 months following acute stroke to avoid a perceived risk of cerebral haemorrhage. We investigated whether early CEA reduces early recurrent stroke and improves outcome in partial anterior circulation infarction (PACI). METHODS: Patients with PACI and a Barthel score of >18 before stroke underwent carotid duplex and CT imaging within 7 days of stroke. Forty consenting patients fit for surgery with greater than 70% ipsilateral carotid stenosis were randomised, 19 to 'early' (within 24 h) and 21 to 'delayed' surgery (at 8 weeks). Modified Rankin and Barthel scores were recorded at 1 week, 2 months, 6 and 12 months. RESULTS: Rankin scores improved more rapidly following 'early' surgery to a score of 1 (0-4) at 2 and 6 months compared with 2.5 and 2 (1-4), respectively, for delayed surgery (p < 0.05). Barthel scores were also significantly improved following 'early' CEA at 7 days but both groups reached a median score of 20 by 2 months. Four 'delayed' and 3 'early' patients suffered extension or recurrence of neurological deficits with 1 death in each group. CONCLUSIONS: Early CEA within 7 days of ischaemic stroke improved functional outcome with earlier hospital discharge. A large multicentre study is needed to exclude the possibility that 'early' CEA increases the risk of cerebral haemorrhage or death.     

Seizures after stroke : a prospective clinical study

Stroke is one of the most common causes of epilepsy in elderly. However, there have been very few prospective studies to define the incidence, pattern and outcome of seizures in stroke. Most studies are based on retrospective analysis of hospital records. Hence, we planned this prospective study to see the clinical, radiological and electroencephalographic characteristics of seizures in stroke and their outcome, from a north Indian tertiary care centre. Over a span of approximately 6 years, 269 consecutive patients with stroke were studied and followed up. Thirty-five (13%) of these developed seizures, primarily related to stroke, during mean follow up period of 15.9 months. Twenty of these had infarctions while 15 had haemorrhages. Involvement of the cortical region was seen in most of the patients with seizures. In these patients, 86% of the lesions involved cortical areas exclusively or in addition to subcortical areas on CT scan of the brain. Twenty-seven (77%) developed early seizures, two third of them had immediate post-stroke seizures. None of the patients with early onset seizures developed recurrent seizures or epilepsy, while 50% of late onset seizures developed epilepsy. No specific EEG pattern was found in those who later developed epilepsy. In the present study, early onset seizures after stroke were rather common and did not affect outcome and did not recur even when not treated with anti-epileptics. Late onset seizures were less common but were associated with recurrent seizures.     

How to diagnose and treat post‐stroke seizures and epilepsy

Stroke is one of the commonest causes of seizures and epilepsy, mainly among the elderly and adults. This seminar paper aims to provide an updated overview of post‐stroke seizures and post‐stroke epilepsy (PSE) and offers clinical guidance to anyone involved in the treatment of patients with seizures and stroke. The distinction between acute symptomatic seizures occurring within seven days from stroke (early seizures) and unprovoked seizures occurring afterwards (late seizures) is crucial regarding their different risks of recurrence. A single late post‐stroke seizure carries a risk of recurrence as high as 71.5% (95% confidence interval: 59.7–81.9) at ten years and is diagnostic of PSE. Several clinical and stroke characteristics are associated with increased risk of post‐stroke seizures and PSE. So far, there is no evidence supporting the administration of antiepileptic drugs as primary prevention, and evidence regarding their use in PSE is scarce.     

Acute seizures in acute ischemic stroke: does thrombolysis have a role to play?

Seizures appear at stroke presentation, during the acute phase or as a late complication of stroke. Thrombolysis has not been investigated as a risk factor despite its potential neurotoxic effect. We try to identify risk factors for seizures during the acute phase of ischemic stroke in a cohort including thrombolysed patients. We undertook a case–control study at a single stroke center using data from Acute Stroke Registry and Analyse of Lausanne (ASTRAL). Patients with seizure occurring during the first 7 days following stroke were retrospectively identified. Bi-variable and multivariable statistical analyses were applied to compare cases and randomly selected controls. We identified 28 patients experiencing from seizures in 2,327 acute ischemic strokes (1.2 %). All seizures occurred during the first 72 h. Cortical involvement, thrombolysis with rt-PA, arterial recanalization, and higher initial NIHSS were statistically associated with seizures in univariated analysis. Backward linear regression identified cortical involvement (OR 7.53, 95 % CI 1.6–35.2, p < 0.01) and thrombolysis (OR 4.6, 95 % CI 1.6–13.4, p = 0.01) as being independently associated with seizure occurrence. Overall, 3-month outcome measured by the modified Rankin scale (mRS) was comparable in both groups. In the subgroup of thrombolysed patients, outcome was significantly worse at 3 months in the seizure group with 9/12 (75 %) patients with mRS ≥3, compared to 6/18 (33.3 %) in the seizure-free group (p = 0.03). Acute seizures in acute ischemic stroke were relatively infrequent. Cortical involvement and thrombolysis with rt-PA are the principal risk factors. Seizures have a potential negative influence on clinical outcome in thrombolysed patients.