• stroke, both ischemic and hemorrhagic, is a significant cause of seizures, especially in the elderly patients
    • stroke accounts for ~ 50% of newly diagnosed seizures among the elderly
    • stroke patients have about an 11.5% risk of single or recurrent seizures in the first 5 years after a stroke (Burn, 1997)
    • the incidence and prevalence of post‐stroke seizures and post‐stroke epilepsy are likely to rise in the future
    • seizures may occur as a consequence of any type of stroke (ischemic stroke, intracerebral and subarachnoid hemorrhage, and cerebral sinus thrombosis with venous infarction)
  • stroke-related (post‐stroke) seizures and stroke-related (post‐stroke) epilepsy (STRE) are common causes of hospital admissions
    • they generally have a favorable prognosis and can be effectively managed using antiseizure medication (ASM)
    • < 25% of cases become drug-resistant
    • seizures may result in increased morbidity, longer hospital stays, significant disability after discharge, and higher resource utilization
  • controlled trials are needed to explore the primary and secondary prevention of STRE and to provide high-quality evidence on the efficacy and tolerability of ASM to guide treatment


The classification of post‐stroke seizure (stroke-related seizure) and post‐stroke epilepsy (stroke-related epilepsy) follows a two-step process:

  • classification of seizures according to standardized diagnostic (revised) guidelines of the International League Against Epilepsy (ILAE)
  • determination of the relation of the seizures to the cerebrovascular event
    • stroke-related seizures – isolated or infrequent seizures that occur as a direct result of a stroke and may be early or late-onset
      • early-onset seizures (within 7-14 days of stroke onset, with a peak within 24 hours)
        • the time frame varies in different clinical definitions and reports; generally, they occur soon after stroke onset
        • early-onset seizures belong to acute symptomatic seizure (ASS)
        • early seizures are believed to be the consequence of local metabolic disturbances
      • late-onset seizures (> 7-14 days after stroke onset)
        • late seizures are thought to occur when the brain has acquired a predisposition to seizures
        • late-onset seizures have a higher recurrence rate
    •  stroke-related epilepsy (STRE)
      • refers to recurrent seizures attributed to a stroke, indicating a chronic condition that requires long-term management (often with antiseizure medications)
      • STRE develops in about 1/3 of early-onset and 50% of late-onset seizures  (Olsen, 2001)
  • acute symptomatic seizures (ASS) occur in close temporal association with an acute cerebral insult or disturbance
  • the time frame for ASS is typically within 7 (14) days of the event (such as stroke, traumatic brain injury, metabolic disorder, or infection)
  • unlike epilepsy, which involves recurrent seizures without a clear immediate cause, ASS are directly related to the transient disturbance caused by the acute condition


  • early-onset seizures after ischemic strokes are often caused by metabolic disorders
    • increase in intracellular Ca2+ and Na+ with a resulting lower threshold for depolarisation, glutamate excitotoxicity, hypoxia, metabolic dysfunction, global hypoperfusion
    • seizures after hemorrhagic strokes are thought to be attributable to irritation caused by products of blood metabolism
  • late-onset seizures and STRE are associated with persistent changes in neuronal excitability and gliotic scarring that disrupt the normal neuronal network
    • these changes can lead to hyperexcitability and epileptogenic foci
    • the location and extent of the cerebral insult significantly influence the risk of epilepsy
    • hemosiderin deposits after a hemorrhagic stroke are thought to be the cause of an increased irritability

Risk factors

  • key risk factors associated with a higher incidence of post‐stroke seizures include
    • stroke severity
    • multiple / larger lesions
    • cortical lesion or hippocampal involvement
    • hemorrhagic strokes
      • ICH: parenchymal location, presence of malformation
      • SAH: MCA aneurysm, concomitant intraparenchymal hematoma
    • pre-existing structural brain conditions
    • patient age
  • early-onset seizures increase the risk of developing epilepsy

Clinical presentation and diagnostic evaluation

Clinical presentation

  • seizures typically follow a localization-related semiology
    • ~ 2/3 of patients present with focal seizures
    • generalized tonic‐clonic seizures are more common in late-onset seizures
    • status epilepticus develops in less than 10% of cases
  • it may not be always clear whether the patient is having seizures
    • post‐stroke seizure, particularly in older people, may present with acute confusion, slowing, behavioral changes, and syncope. These symptoms also frequently lead to a misdiagnosis of stroke recurrence, especially when the patient has postictal paresis (Todd’s paralysis)
    • consider atypical presentations of seizure and stroke mimics

Diagnostic evaluation

  • diagnosis involves a comprehensive assessment, including:
    • patient history
    • neurological examination
    • electroencephalography (EEG)
      • EEG is crucial in differentiating epileptic seizures from other phenomena, such as TIAs or migraine auras
      • EEG may be normal in about 5% of cases ⇒ normal EEG does not exclude epileptogenicity
      • focal spikes or periodic bilateral discharges are associated with a higher risk of seizures
    • neuroimaging
      • essential for identifying the epileptogenic zone and assessing the extent of brain damage
      • MRI brain is the imaging modality of choice, as it shows a number of abnormalities that may be missed on CT (cortical malformations, hippocampal sclerosis, small mass lesions, and temporal lobe cavernomas)


  • antiseizure medications (ASMs) remain the mainstay of epilepsy management in all age groups
  • stroke etiology, side effect profiles, and patient comorbidities should be considered when selecting the appropriate drug
    • newer AEDs with fewer side effects and drug interactions are preferable, such as levetiracetam (LEV)
  • non-pharmacological interventions, such as surgery, may be considered in drug-resistant cases
  • the general principles used for managing other types of epilepsy also apply to post-stroke seizures and epilepsy
    • inform the driving licence agency
    • advice on supervision of activities such as swimming, cooking, etc
    • schedule regular follow-ups to monitor for and address any potential drug side effects

Choice of antiseizure medications

  • preferred choice in the acute phase: valproic acid (VPA), levetiracetam (LEV), and lacosamide(LCM), as they allow rapid parenteral titration
  • phenytoin (PHE) has potential interactions with anticoagulants
  • for long-term medication, consider carbamazepine (CBZ), VPA, LEV
    • the specific choice will depend on individual factors and potential side effects

Duration of antiseizure medications

  • optimal duration of antiseizure medication (ASM) is unknown
  • risk of epilepsy is approx. 5-11% (higher in patients with parenchymal hemorrhages and focal neurological deficits)
    • most late-onset seizures occur within the first year
    • late-onset seizures are more common in patients with early-onset seizures
  • duration should be guided by stroke etiology, the presence and extent of parenchymal lesions, EEG findings, and the timing of epileptic seizures (early x late)
  • no strict recommendation; an individualized approach is advised to avoid unnecessary long-term ASM use
    • isolated symptomatic seizure (<2 weeks after stroke onset) without large parenchymal lesion ⇒ AED therapy can be gradually tapered within 2-4 weeks after the acute phase
    • isolated symptomatic seizure or multiple ASS with parenchymal lesion and/or pathological EEG ⇒ continue ASM treatment for up to 12 months
    • post-stroke epilepsy (at least two seizures > 2 weeks after stroke onset) ⇒ long-term ASM is reasonable

Prophylactic use of antiseizure medications

  • ischemic stroke: prophylactic use of antiseizure medication (ASM) is not recommended for ischemic stroke (AHA/ASA 2013 III/C)
  • CVST: prophylactic treatment in the first 7-14 days after diagnosis of CVST may be considered (based on the ICSVT study results)
    • patients with hemiparesis and parenchymal lesions are at higher risk for ASS
    • prophylactic treatment does not lower the risk of post-CVST epilepsy
  • SAH: prophylactic antiseizure medication is not routinely recommended; prophylactic therapy in the first 7-14 days may be considered in individual cases to prevent aneurysm rupture during a seizure
  • ICH: prophylactic antiseizure medication is not routinely recommended


  • specific prevention of post-stroke epilepsy is not possible
  • however, recanalization therapy and treatment and prevention of complications may reduce the extent of permanent brain damage (extent of lesion and stroke severity are significant risk factors for STRE)

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Stroke-related epilepsy (STRE)
link: https://www.stroke-manual.com/stroke-related-epilepsy-stre/