Poststroke epilepsy: epidemiology, pathophysiology and management

Seizures and status epilepticus can be a presenting feature of acute stroke. They may occur in its early (<7 days) clinical course or be a remote (>7 days) complication. Most seizures are single, either partial or generalised. Early and remote seizures seem to have different predictors and pathogenesis. Seizures are more frequent in severe and disabling strokes, haemorrhagic strokes and those with cortical involvement. The risk of epilepsy is higher for patients with early seizures, cortical infarctions and lobar haemorrhages and in dependent patients. Early or remote seizures do not have a significant influence on dependency or mortality, although seizures and status epilepticus can be a direct cause of death. Treatment can be started after a first or a recurrent seizure. Treatment options include phenytoin, carbamazepine, valproic acid (valproate sodium) and the new antiepileptic drugs (AEDs). New AEDs can be used to decrease the likelihood of drug interactions and adverse effects in patients who do not tolerate the classic AEDs and in treatment failures with classic AEDs. Large observational studies to define prognostic factors for poststroke seizures in specific stroke subtypes are needed. Randomised controlled trials of AED prophylaxis for acute and remote seizures are essential to improve the evidence level of current guidelines and recommendations.