Reperfusion Therapies and Post-Stroke Seizures: Evidence, Mechanisms and Clinical Implications-A Narrative Review

Seizures are a frequent complication of stroke and are often linked to worse functional outcomes. With advancements in acute stroke care, particularly the use of reperfusion therapies (RTs) such as intravenous thrombolysis, intra-arterial therapies and mechanical thrombectomy, the relationship between these treatments and post-stroke seizures (PSS) requires re-evaluation. This review explores the mechanisms connecting RTs to acute symptomatic seizures (ASS) and post-stroke epilepsy (PSE), summarises current evidence on their association and identifies gaps in knowledge to guide future research. A literature search was conducted using PubMed, Scopus, Cochrane and Google Scholar, focusing on terms such as "seizures," "epilepsy," "stroke," "thrombolysis," "rtPA," "reperfusion therapies," and "thrombectomy." The reported frequency of seizures following thrombolysis was 4%-15%, with RTs potentially influencing PSS through complex, sometimes opposing, mechanisms. While some studies suggested that RTs could increase seizure risk due to factors like reperfusion injury or haemorrhagic transformation, others proposed a protective effect by reducing infarct size and stroke severity. Current evidence does not confirm a strong link between RTs and PSS, and most research has focused on ASS rather than PSE. The pathophysiology of seizures in this context remains unclear, with multiple contributing factors. The effect of RTs on PSS is poorly understood, highlighting the need for better definitions of seizures, standardised monitoring and high-quality, multicentre prospective studies. Leveraging stroke registries and addressing clinical challenges, such as stroke characteristics and reperfusion success, are critical to clarifying this relationship and improving stroke care.