Imogen Milner MS/Epilepsy SCN May 2018 Stroke and Seizures Imogen Milner MS/Epilepsy SCN May 2018

Stroke is the main cause of epilepsy in older people accounting for 11% of all adults epilepsies and 45% of epilepsy diagnosis over the age of 60. An older person presenting with first seizure has 2-3 fold increased risk of stroke

Definition of Epilepsy (ILAE 2014) Epilepsy is a disease of the brain defined by any of the following conditions: At least two unprovoked (or reflex) seizures occurring more than 24 hours apart One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years Diagnosis of an epilepsy syndrome

What is a seizure? “An epileptic seizure is a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neural activity in the brain.” ILAE 2005

Early Seizures (acute symptomatic seizures) Late Seizures (unprovoked seizures) <7 days >7 days IS 1-13%, ICH 4-28% IS = ICH >first 24 hours 2-15% over 10 years Secondary to acute neuronal injury Secondary to gliosis, neurodegeneration Marker of stroke severity Meets diagnosis of epilepsy (55-90% reoccurrence)

Status epilepticus 1) Some define as >30mins more recently >5 mins -spontaneous resolution decreases over time -Prolonged convulsion = neuronal injury = ↑risk of pharmacoresistance 2) Intermittent seizures without regained consciousness lasting 30min or longer Post stroke risk 0.2% IS and 0.3% ICH Mortality risk of 11-34% * Consider nonconvulsive status if delirium present Interestingly if SE first epileptic manifestation post stroke it is not usually followed by other seizures.

Risk factors: Haemorrhagic stroke High NIHSS Cortical involvement Haemorrhagic transformation Total anterior circulation infarcts Young age Surgical intervention Alcohol Low APTT High glucose t-PA Additional strokes

Seizure versus stroke Focal seizures may be missed: Intermittent eye deviation Speech impairment Worsening motor function Altered mental state Misdiagnosed as seizures: Involuntary movements – TIA’s, Syncope, different stroke locations, Tics, Metabolic derangements

focal to bilateral tonic-clonic ILAE 2017 Classification of Seizure Types Expanded Version1 Focal Onset Generalized Onset Unknown Onset Aware Impaired Awareness Motor tonic-clonic clonic tonic myoclonic myoclonic-tonic-clonic myoclonic-atonic atonic epileptic spasms2 Non-Motor (absence) typical atypical eyelid myoclonia Motor tonic-clonic epileptic spasms Non-Motor behavior arrest Motor Onset automatisms atonic2 clonic epileptic spasms2 hyperkinetic myoclonic tonic Non-Motor Onset autonomic behavior arrest cognitive emotional sensory Unclassified3 1 Definitions, other seizure types and descriptors are listed in the accompanying paper and glossary of terms. 2 These could be focal or generalized, with or without alteration of awareness 3 Due to inadequate information or inability to place in other categories focal to bilateral tonic-clonic From Fisher et al. Instruction manual for the ILAE 2017 operational classification of seizure types. Epilepsia doi: 10.1111/epi.13671

Focal onset Sensory, vertigo, Visual hallucination Focal motor, Nocturnal, bizarre Movements, no post ictal confusion Visual images, vomiting, headache, photosensitivity Smell, De ja vu, detachment, dysphasia

To treat or not to treat? Seizure versus epilepsy Type of seizure Goals Co-morbidities Concomitant medications Treatment options Side effects

European Stroke Organisation guideline summary for questions re IS and ICH Rx: Does AED prophylaxis prevent ASS? Risk of Sz does exceed 35% so not justified If 1 x ASS will AED prevent reoccurrence? 10 year risk of unprovoked seizure is 30% so not justified Does AED prevent unprovoked seizure? In general risk <50% so not justified If 1 X unprovoked seizure does AED prevent further seizures? High risk of reoccurrence AED should be considered Does Rx with AED affect functional outcome? No evidence to support so not justified Does Rx with AED prevent mortality? IIS: Ischaemic stroke, ICH: intracerebral haemorrhage, Rx: treatment, AED: antiepileptic drug, ASS: acute symptomatic seizure

Education: Risk of seizure ASS and long term unprovoked including different pathophysiological causes First aid for seizures Safety Social support network Professional supports Medication education Recognition of possible side effects

What do you do? Safety ABC +/- Oxygen Maintain dignity Excessive saliva / blood put head to the side If vomiting and at cessation of seizure put into recovery position Place a pillow/jacket under the head Don’t put anything into their mouth Don’t move the person unless safety compromised Don’t restrain the person Remove sharp objects Maintain dignity Don’t leave the person alone Let them know what has happened Don't give the person anything to eat or drink until they are alert If focal give reassurance. Lead to safety. Don’t assume they are alert. If possible time the seizure +/- when to call the ambulance

Thank you Recommended Articles: Xu, M (2018) Poststroke seizure: optimising its management Zelano, J (2016) Poststroke epilepsy: update and future directions Holtkamp,M et al (2017) European Stroke Organisation guidelines for the management of post-stroke seizures and epilepsy