Seizures post Stroke

Contents
Ø Epidemiology
Seizures post Stroke
Elizabeth Dempsey
C.N.S. Neurology
Mater Misericordiae University Hospital
post Stroke Seizures
Ø Classification of Seizures
Ø Possible Causes of Post Stroke Seizures
Ø Early & Late post Stroke Seizures
Ø Recording of Seizures
Ø Management /Pharmacology
Ø Psychosocial Impact/Education/lifestyle
Epidemiology of Seizures post
Stroke
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Stroke; leading cause of symptomatic Epilepsy in Adults,
(Neurology,2006,Ryvlin et al)
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Prevalence & incidence Epilepsy rises with age, 1/3 new
Seizures 2nd Stroke (Sander,1996 &Panayiotopoulos 2008)
Stroke 30%new Dx Epilepsy> 60 years
10-15% with acute Stroke/TIA: present Seizure.>30%
seizure/48hrs (Crino/Delanty2002)
54-66% single seizure,2-4%develop epilepsy (Ryvlin et al
Seizure/Epilepsy
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2006)
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5% seizures are marker for Stroke ((Manford
Manford 2003)
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Epilepsy,3rd most common Neurology disorder after
Stroke, Dementia (Tallis,2002)
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Seizure is a sudden, paroxysmal, synchronous
repetitive discharge of Cerebral Neurons that
interrupt brain function (Brainwave 2009) +/- alteration
of consciousness
Epilepsy is the tendency to have recurrent
unprovoked seizures.37,000 people in Ireland
with Epilepsy (Linehan et al 2009)
Post Stroke Epilepsy recurrent unprovoked late
onset seizures(Cavazos,2004)
Neurological Complication post
Stroke: Seizures
Cause of Seizures
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Previous Stroke 30-40%
1% patients >65yrs; 20-40% 2nd Stroke
Asymptomatic Cerebral infarction (Brodie,Kwan 2005)
Alzheimer's & Dementia risk of seizures
Brain Tumors, Head trauma
Alcohol withdrawal seizures
Systemic Disorders; Metabolic, Electrolyte,
C.N.S.infections,
C.N.S.infections,
Medications:antipsychotics
Medications:antipsychotics,,
antidepressants,antibiotics
Alcohol/Substance Abuse
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Early post Stroke seizures; (E.P.S.) Acute
Symptomatic, 6%<7/7
Late post Stroke Seizures (L.P.S.);>7/-7/months
L.P.S.;3% year1,4.7% year 2,7.4%year 5,
8.9%10 yrs
Onset, E.P.S.: simple partial,complex-partial,2nd
generalized tonic clonic (G.T.C.)
Early seizures>post stroke epilepsy,2nd structural
brain abnormalities/focus (Crino,Delanty,2002)
L.P.S., Post Stroke Epilepsy, recurrent
unprovoked late onset seizuresG.T.C.(Cavazos,2004)
Immediately
Ø Partial type seizures in Ischaemic or haemorrhagic Stroke (Stroke
1998)
Ø No correlation of acute Seizures with size of lesion,functional
outcome mortality (Crino,delanty,2002)
Early or Late post Stroke Seizures
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Acute Stroke most common cause of seizures in the
elderly
Risks; Early seizure, location; cerebral cortex & severity
of stroke
8% Haemorrhagic Stroke(
Stroke(I.C.H),develop seizures after
2/52
5% Ischaemic Stroke.(BMJ,2005,Brodie,Kwan) ?Ischaemic Stroke Rx
Partial/focal Epilepsy
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63% Partial seizures not recognised
Limb jerking, tingling
Atypical features, memory lapses, confusion,
inattention (Brodie,
Brodie, Kwan 2005)
Symptoms in seconds-minutes
Spread – adjacent areas
Resolve minutes-hours
Partial/aura – C.P.S. -2nd generalisation
? persistent Neurological signs
Differential Diagnosis
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Funny Turns
Syncope
Hypoglycaemia /Hyperglycaemia
/Hyperglycaemia
T.I.A.
Migraine
Trans Global Amnesia
Vertigo/non specific dizziness(Shorovon,2000)
Todd’
Todd’ s paresis (temporary reduction in motor
function activated at onset of attack, resolves
approx 30 mins,Manford2003)
Risks for Seizures in Stroke
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Age
Cocaine Abuse>rise Stroke/I.C.H/seizures
Alcohol
Cerebro Autosomal Dominant Arteriopathy with
Subcortical Infarcts &
Leukoencephalopathy(C.A.D.A.S.I.L.)
Leukoencephalopathy(C.A.D.A.S.I.L.)
Arterial-Venous Malformation (A.V.M.)
Cerebral Amyloid Angiopathy (C.A.A.)
Mitochondrial Encephalomyopathy,
Encephalomyopathy, Lactic Acidosis &
Stroke (M.E.L.A.S.) Stroke like episodes & seizures
Rheumatic heart disease, Endocarditis,
Endocarditis, Mitral valve
prolapse
Reperfusion syndrome, Carotid Endarterectomy,
Endarterectomy,
Sickle Cell Disease
Diagnostic Considerations
E.E.G. Changes
Ø 1st
Ø Elderly;
Ø ? 2nd
Ø Slow
seizure
illness
Ø History, witnessed account
Ø Vital signs
Ø Laboratory/toxicology
Ø C.T. scan/M.R.I.
Ø E.E.G.
variety of changes
activity, normal variant after 50 years
Ø Sharp spikes, sleeping, drowsy with >age
To Treat or not to Treat ??
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Prophylactic Rx ? if seizure onset< 24hrs
Prophylactic Rx in I.C.H. with cortex, beneficial
(Crino/Delanty,2002)
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Treat if seizure>7/7 post stroke, late onset
seizures; long term treatment (A.C.N.R.2011)
Single seizure/classification/E.E.G.
Women, Acceptance, Contraception, Folic Acid
Treatment aim; seizure control with no side
effects
Start low, dose & titrate slowly to avoid toxicity
Pharmacokinetics
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Biological age V’
V’s chronological age
Complex pharmacokinetics, Protein Binding
reduced, Albumen concentrations lowered
½ life increased as metabolism slower
Interaction of other medications complicates
absorption, clearance, elimination
Limited drug trials for elderly population with
seizures post Stroke
Compliance; memory, cognition, intellect,
Adverse effects, drug toxicity, lower serum
levels(Shorvon,2000)
Seizure Medication
Concerns for Rx
Ø Bone
Mineral density reduced after Stroke,
hemiplegic side,
Ø Fracture Risk increased: duration of
immobility, severity of hemiplegia,
hemiplegia, time
after menopause
Ø Influencing factors; recovery, hemiplegia
Ø vitamin D, warfarin ( Kenneth,Poole et al,Stroke 2002)
(Anti Epileptic Drugs/A.E.D.’
Drugs/A.E.D.’S)
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Phenytoin PHT
Phenobarbital PHB
Sodium valproate VPA
Carbamazepamine
CBZ
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Mysoline PMD
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Concerns of A.E.D. for Stroke &
Epilepsy
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Use of aed’
aed’s,# risk; CBZ,PHB,OXC,VAL
Enzyme inducing PHT,CBZ,&PHB
Continued AED use higher risk of bone loss @
hip – # x 5 yrs Epilepsy # 2-6 >gen
>gen population,
chronic steroid use (Neurology 2004)
Falls common in epilepsy 2nd C.N.S. effects
>seizures, ataxia, altered sensation, cognitive
impairment
Immobility, inactivity, few weight bearing
activities, residential care, focal weakness osteopenia
A.E.D. options in Stroke
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Psychosocial Implications
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Impact of Seizures/misconceptions
Injuries, osteoporotic fracture
Quality of Life
Driving
Employment
Drug payment/Medical Card/Long term
Illness/Drug refund scheme
Lamotrigine LTG
Levetiracetam LEV
Topiramate TPM
Oxycarbazepine OXC
Zonisamide ZNG
Gabapentin GBT
TiagabineTGB
Rufinamide
Lacosamide
I.L.A.E. Gabapentin(GBT)
Gabapentin(GBT) &
Lamotrigine(LTG),1ts line monotherapy for
partial Epilepsy
Gbt 81%seizure free @ 30/12 e.g.(9001200/od)
Lct 100-150/od
?Oxcarbazepine & Levetiracetam benefit elderly
post Stroke patients
Education
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Collaborative decision re Rx
Information re medications/benefits/potential side
effects/documentation of titration
Written instructions, careful explanation, Blister packs
Advice re Seizure Safety
Reduce Seizure triggers:
Adequate sleep/hydration/nutrition/compliance with
a.e.d’
a.e.d’s.
Avoid heights/use shower instead of baths/ avoid
swimming alone/reduce c2H5oH
Support Group, Irish Epilepsy Assocation;Brainwave,
Assocation;Brainwave,
www.epilepsy.ie
Conclusion
Ø Seizures
in Stroke patients,
Challenging/Ambiguities
Ø Minimal research on Elderly patients with
A.E.D.’
A.E.D.’S
Ø Risk/Benefit options
Ø Continuous Observation of Stroke patients
Thank You