Post Stroke Epilepsy (PSE)

Related Subjects: |Status Epilepticus (Epilepsy) |Coma management |Lorazepam |Phenytoin |Levetiracetam |Epilepsy - General Management |First Seizure |Epilepsy in Pregnancy |Febrile seizures

Post-Stroke Epilepsy (PSE) = recurrent seizures after a cerebrovascular event. Key definition ➝ seizures occurring >7 days post-stroke (late seizures). ⚠️ Early seizures (≤7 days) are acute symptomatic and do not alone constitute epilepsy. PSE impacts rehab, quality of life, and mortality risk in stroke survivors.

📊 Epidemiology

• Incidence among stroke survivors: ~5–15% within 5 years.
• By stroke type:
  • Ischemic: 2–14%
  • Hemorrhagic: 10–20%
• Early seizures: 3–6% (predictor of later epilepsy).
• Late seizures: 1–4% (true PSE).

⚠️ Risk Factors

• Large infarcts, severe neurological deficits.
• Cortical involvement (especially temporal/parietal ➝ supramarginal & superior temporal gyri).
• Hemorrhagic stroke / hemorrhagic transformation of infarct.
• Early seizures after stroke ➝ predictor of later PSE.
• Temporal lobe lesions ➝ risk of temporal lobe epilepsy.
• Younger age (<65) ➝ more likely to survive to manifest epilepsy.
• Pre-existing cortical malformations or scarring.

🔬 Pathophysiology

• Glial scarring ➝ abnormal excitatory circuits.
• Neuronal hyperexcitability (altered channels, receptors, neurotransmitters).
• Blood breakdown products (iron, haemosiderin) irritate cortex in ICH.
• Post-stroke inflammation fuels epileptogenesis.

⚡ Clinical Features

• Focal seizures (most common):
  • With impaired awareness ➝ automatisms, staring, altered consciousness.
  • Without impaired awareness ➝ motor jerks, sensory symptoms.
• Secondary generalisation ➝ tonic-clonic seizures.
• Status epilepticus (rare but life-threatening).
• Onset: months to years post-stroke, beyond acute phase.

🧾 Differential Diagnosis

• Transient Ischemic Attack (TIA)
• Recurrent/new stroke
• Metabolic derangements (Na⁺, Ca²⁺, glucose)
• Infections (CNS/systemic)
• Medication side effects
• Alcohol withdrawal seizures
• Movement disorders mimicking seizures

🧪 Investigations

• Bloods: CBC, U&E, LFTs, glucose, Ca²⁺.
• Imaging:
  • CT ➝ rule out haemorrhage or new infarct.
  • MRI ➝ sensitive for gliosis, cortical scarring.
• EEG: focal spikes/sharp waves; helps confirm epilepsy.
• Chest X-ray ➝ aspiration/infection check.
• ECG ± echo ➝ rule out cardiac embolic causes if relevant.

🚑 Acute Management

• Seizure first aid: airway, protect from injury.
• Benzodiazepines (IV lorazepam) for prolonged seizures/status.
• Correct triggers ➝ glucose, Na⁺, infection, offending meds.

💊 Long-Term Management

• First-line AEDs: Levetiracetam, Lamotrigine (safe in elderly, few interactions).
• Alternatives: Valproate, Carbamazepine, Phenytoin (caution: interactions with anticoagulants/statins).
• Start low, titrate gradually; adjust for renal/hepatic function.
• Follow-up: monitor efficacy, drug side effects, bloods where relevant.
• Rehabilitation: physio, OT, speech therapy as per stroke recovery.
• Patient education: adherence, seizure triggers, safety at home, avoid swimming/bathing alone.
• Driving: Follow DVLA guidance (UK: usually seizure-free ≥12 months before license return).

📈 Prognosis

• Many achieve seizure control with AEDs.
• PSE may worsen rehab outcomes & QoL.
• Risk of recurrence: ↑ with cortical strokes, early seizures, severe stroke.
• Complications ➝ status epilepticus, aspiration pneumonia, injury.

✅ Conclusion

Post-stroke epilepsy is a common and impactful sequela of stroke. Recognition, prompt AED therapy, and multidisciplinary support are vital to minimise disability and optimise recovery. Prevention trials are ongoing, but current focus = risk factor control + seizure suppression.

📚 References

• Haapaniemi E, Strbian D, Rossi C, et al. Acute seizures after intracerebral haemorrhage. Neurology. 2014.
• Silverman IE, Restrepo L, Mathews GC. Poststroke seizures. Arch Neurol. 2002.
• Beghi E, D'Alessandro R, Beretta S, et al. Incidence and predictors of acute symptomatic seizures after stroke. Neurology. 2011.
• ILAE. Definition of Epilepsy 2014. ILAE Website.