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

2. 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

3. 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

4. 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

5. 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)

6. 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.

7. 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

8. 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

9. 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: /epi.13671

10. 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

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

12. 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

13. 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

14. 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

15. 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