
Seizures after a stroke are most likely to occur within the first few days following a stroke, but they can also occur years later. The risk of having a seizure lessens over time after a stroke. Acute onset seizures usually happen within 24 hours of the stroke.
The likelihood of having a seizure after a stroke is increased if the stroke was severe, caused by bleeding in the brain (a haemorrhagic stroke), or affected the cerebral cortex.
If you have a seizure after a stroke, it does not necessarily mean you have epilepsy or will develop it. However, if you have chronic seizures and more than one per month, you are at a higher risk of developing epilepsy.
Characteristics | Values |
---|---|
Time of occurrence | Within 24 hours to years after a stroke |
Risk factors | Having a severe stroke, a stroke caused by bleeding in the brain (haemorrhagic stroke), a stroke in the cerebral cortex, embolic stroke, cortical damage, hippocampus involvement, middle cerebral artery aneurysm, intraparenchymal haematoma, structural brain lesions, EEG abnormalities, partial type seizures |
Type of seizure | Focal (shaking of one part of body with or without loss of awareness), focal with secondary generalization (also called focal to bilateral seizures), tonic-clonic (generalised) |
Status epilepticus | Occurs in 9% of cases |
Treatment | Antiseizure medications |
What You'll Learn
Seizures after stroke: causes and risk factors
Seizures are caused by a sudden abnormal burst of electrical activity in the brain, which disrupts the electrical signals being sent to the rest of the body. This electrical disturbance can be caused by stroke damage to the brain.
Seizures are most likely to occur within the first few days after a stroke, but they can also occur years later. The risk of having a seizure reduces over time after a stroke. Acute onset seizures normally happen within the first 24 hours after a stroke.
You are more likely to have a seizure after a stroke if the stroke was severe, caused by bleeding in the brain (a hemorrhagic stroke), or if it occurred in the cerebral cortex, the large outer layer of the brain where vital functions like movement, thinking, vision and emotion take place.
Other risk factors include:
- Age: patients under 65 are more likely to develop seizures than older patients.
- Recurrent strokes: the risk of seizures is higher if the patient has had more than one stroke.
- Stroke severity: the larger the injury to the brain, the more likely a seizure is to occur.
- Type of stroke: hemorrhagic strokes are more likely to lead to seizures than ischemic strokes.
Developing seizures after a stroke may increase the risk of death or disability. Patients who have seizures after a stroke are also more likely to be diagnosed with epilepsy.
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Seizure types and symptoms
Seizures can vary, ranging from tingling sensations or 'going blank' for a few seconds, to shaking and losing consciousness. Some people have only one type of seizure, and some have more than one type.
There are three main types of seizure:
Focal Onset Seizures
Some seizures only occur in part of the brain, known as focal onset seizures. There are two kinds of focal seizures: motor (physical signs like moving arms or falling) and non-motor (which affects senses, awareness and emotions).
Generalised Onset Seizures
A generalised seizure involves the whole brain and affects the whole body. Motor (physical) signs can include losing consciousness and muscle spasms. A non-motor seizure could be a brief period of absence or blankness, where the person stops moving and looks as if they are staring into space.
Unknown Onset Seizure
If it's not possible to tell where the seizure began in the brain, doctors may describe your seizure as motor or non-motor. Motor (physical) signs might include losing consciousness and having jerking movements, and non-motor signs can affect emotions and sensations.
Status Epilepticus
Status epilepticus is a condition in which a person has an abnormally long seizure or doesn’t regain consciousness between seizures. This is life-threatening, and an ambulance should be called. Longer than 5 minutes is too long for a seizure to last.
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How to help someone having a seizure
Seizures are a common occurrence, with 1 in 10 people likely to have one at some point in their lives. They can be scary to witness, but there are some simple steps you can take to help someone having a seizure and keep them safe. Here are some instructions on how to help:
- Keep yourself and others calm. Try to stay relaxed and calm any bystanders.
- Stay with the person. It is important not to leave them alone.
- Remove any objects nearby that could cause injury and cushion their head if possible.
- If they are wearing a medical bracelet, check it for information about their condition, medicines, and emergency contacts.
- If the person is lying down, gently turn them onto their side with their mouth pointing downwards to keep their airway clear.
- Time the seizure. Keep track of how long it lasts. If it continues for more than 5 minutes, seek immediate medical attention by calling an ambulance.
- After the seizure, help the person sit or lie down in a safe place to recover. Offer comfort and explain what happened once they are alert.
- If necessary, offer to call a friend or loved one to help them get home safely.
It is important to note that you should not hold the person down, restrict their movements, or put anything in their mouth during a seizure. This could cause injury to you or the person having the seizure. Additionally, do not offer them food or water until they are fully alert to avoid choking.
While seizures can be frightening, most seizures are not an emergency and will stop on their own without causing any permanent harm. However, there are some situations in which you should call an ambulance or seek immediate medical attention:
- The person is having a seizure for the first time.
- The seizure lasts longer than 5 minutes.
- The person has another seizure soon after the first one.
- The person has difficulty breathing or waking up after the seizure.
- The person is injured during the seizure.
- The seizure occurs in water.
- The person has diabetes and loses consciousness.
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Treatment for post-stroke seizures
Post-stroke seizures can be treated with anti-seizure medications, which can often fully control stroke-related epilepsy. The type of medication and treatment will depend on the type of seizures, their frequency, and other factors such as swallowing problems or other medication the patient is taking.
Anti-epileptic drugs (AEDs) are usually the first course of treatment. AEDs work by changing the levels of chemicals in the brain. Side effects may include drowsiness, dizziness, and confusion, but these may lessen or disappear as the body gets used to the medication. Doctors will usually start patients on a low dose and increase it gradually to reduce the chances of side effects. If side effects are severe or long-lasting, doctors may change the dose or try a different medication.
If anti-epileptic drugs are ineffective or the epilepsy is due to a physical cause in the brain, surgery may be an option. However, this is very risky and depends on where the problem is located in the brain and whether a surgeon can reach it safely.
Vagus nerve stimulation therapy is another treatment option, usually for children (and occasionally adults) who don't respond to AEDs. This involves implanting a small electrical device in the neck, which connects to the left vagus nerve and sends regular electric signals to the brain to help regulate electrical activity.
Preventing post-stroke seizures
The Stroke Council of the American Heart Association recommends seizure prophylactic treatment in the acute phase for intracerebral and subarachnoid haemorrhages. Patients with seizure activity more than two weeks after presentation have a higher risk of recurrence and may require long-term anticonvulsant prophylactic therapy.
Managing post-stroke seizures
The general principles of epilepsy management also apply to post-stroke seizures. This includes informing the relevant authorities if the patient holds a driving licence, advice on supervision of activities such as swimming and cooking, a gradual increase of the dose regimen to the maintenance dose, and regular follow-ups to monitor drug side effects.
Challenges and considerations
It is not always clear whether a patient has had a seizure, as they can present with atypical forms, especially in older people. Acute confusional state, slowing, behavioural change, and syncope of unknown origin are a few symptoms that post-stroke seizures can manifest as. Symptoms can also lead to a mistaken diagnosis of stroke recurrence when the patient is actually experiencing post-ictal paresis or Todd's paralysis.
Another important issue, particularly in older adults, is distinguishing a post-stroke seizure from other causes of seizures and from other conditions that can mimic seizures. Syncope, for example, can be associated with incontinence, injury, and a slower recovery with confusion, all of which are also features of seizures. The apparent cause of a seizure (e.g. stroke) may also mask the actual cause, such as neurological, metabolic, or cardiovascular issues.
Multidisciplinary approach
The diagnosis of epilepsy has a significant impact on the patient and their families/carers, so education and counselling should be started in parallel with pharmacotherapy. A multidisciplinary team approach is required, and epilepsy specialist nurses play a vital role in education, counselling, and reassurance.
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Post-stroke epilepsy
The pathogenesis of PSE is complex and involves various factors, including ion channel dysfunction, neurotransmitter imbalance, elevated serum cortisol levels, deposition of hemosiderin, astrocytic proliferation, damage to the blood-brain barrier, and genetic factors. Early-onset epileptic seizures occur within the first week after a stroke and are often associated with metabolic disorders and increased neuronal excitability. Late-onset epilepsy develops more than a week after a stroke and is characterised by the formation of stable epileptic networks.
The management of PSE aims to reduce the risk of seizure recurrence and improve patient outcomes. Anti-epileptic drugs (AEDs) are typically used to treat unprovoked remote symptomatic seizures, as they have a high risk of recurrence. However, the choice of AED should be individualised, considering the patient's age, co-morbidities, and co-medications.
The treatment of PSE is challenging due to the unique characteristics of stroke survivors, and it requires a personalised approach. Prognostic models, such as the SeLECT and CAVE scores, can help assess the risk of developing PSE. Additionally, early electroencephalogram (EEG) and blood-based biomarkers can provide valuable information for risk assessment and treatment planning.
In summary, post-stroke epilepsy is a serious complication that can significantly impact the lives of stroke survivors. The management of PSE requires a comprehensive approach that considers the patient's individual needs and risk factors to prevent seizures and improve their overall prognosis.
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Frequently asked questions
Seizures can occur as early as 24 hours after a stroke, but they can also occur weeks, months, or even years later.
The chances of having a seizure after a stroke vary depending on the type of stroke and the area of the brain affected. The risk is highest in the first few weeks following a stroke, but it can be as high as 10% overall.
Not necessarily. Epilepsy is usually diagnosed when seizures recur and are not directly related to the acute stroke. However, the likelihood of developing epilepsy increases the more delayed the first post-stroke seizure is.
Generally, anti-seizure medications are not recommended for people who have had a stroke unless they start having recurring seizures.