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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 13  |  Issue : 3  |  Page : 166-168

Early-onset seizures in ischemic stroke: A descriptive cross-sectional study


Department of Neurology, Dow University of Health Sciences, Karachi, Pakistan

Date of Submission12-Nov-2021
Date of Decision12-Dec-2021
Date of Acceptance13-Dec-2021
Date of Web Publication13-Jul-2022

Correspondence Address:
Dr. Mohsina Syed
Department of Neurology, Dow University of Health Sciences, Karachi
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injms.injms_132_21

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  Abstract 


Context: Poststroke seizures are not infrequent neurological sequelae of stroke. Aims: The primary aim of our study is to determine the frequency of early seizures in acute ischemic stroke in our population. Subjects and Methods: It is a descriptive cross-sectional study done at the Department of Neurology, Dr. Ruth K. M. Pfau Civil Hospital Karachi, Pakistan. The duration of the study was of 6 months, from July 2019 to December 2019. All patients who fulfilled the inclusion criteria were enrolled in the study after Institutional Review Board approval. Informed and written consent was obtained from all subjects. A detailed history and clinical examination were carried out and all patients were assessed by a trained neurologist. Results: Total 281 patients with ischemic stroke were included. One hundred and eighty-one patients (64.4%) were male and 100 (35.6%) were female with a mean age of 48.41 ± 8.730 years. The early-onset seizures were noted in 22 patients (7.8%). In our study, early-onset poststroke seizures were noted more commonly in the age group of 36–60 years and were predominant in the males. Patients with infarction in the parietal lobe exhibited greater seizure occurrence. The most common seizure type observed was generalized tonic–clonic. Majority of early-onset poststroke seizures occurred in the 1st week. Conclusion: In our study, the frequency of early onset seizures in patients with ischemic stroke was found to be 7.8%, which when occurs increases morbidity.

Keywords: Early-onset seizures, ischemic stroke, poststroke seizures


How to cite this article:
Syed M, Liaquat S, Saleem Z, Singh J, Sana R, Shahbaz NN. Early-onset seizures in ischemic stroke: A descriptive cross-sectional study. Indian J Med Spec 2022;13:166-8

How to cite this URL:
Syed M, Liaquat S, Saleem Z, Singh J, Sana R, Shahbaz NN. Early-onset seizures in ischemic stroke: A descriptive cross-sectional study. Indian J Med Spec [serial online] 2022 [cited 2022 Aug 9];13:166-8. Available from: http://www.ijms.in/text.asp?2022/13/3/166/350793




  Introduction Top


Poststroke seizures are classified based on the time of onset of seizures after cerebral infarction.[1] Early-onset seizures are defined as seizures occurring within the first 14 days and late-onset seizures after 14 days of stroke onset.[1]

The main purpose of this research was to determine the frequency of early-onset seizures after cerebral infarction in our Pakistani population. By conducting this study, we will be able to estimate the frequency of occurrence of early seizures in our population as data are relatively scarce so that adequate measures can be taken early in the management.


  Subjects and Methods Top


We did a descriptive cross-sectional study at the Department of Neurology, Dr. Ruth K. M. Pfau Civil Hospital Karachi. The duration of the study was 6 months from July 2019 to December 2019. The study was approved by the Institutional Review and Ethical Board. Informed and written consent was obtained from all the participants. Patients of either gender, subjects between 18 and 60 years of age, and seizures presenting within 2 weeks of stroke onset were enrolled. The patients with hemorrhagic stroke, late-onset seizures (>14 days), cerebral venous sinus thrombosis, and secondary causes of seizures (hypoglycemia, hyponatremia and hypocalcemia, arteriovenous malformations, and previous history of epilepsy) were all excluded. Early-onset seizures were defined as seizures occurring within 14 days of ischemic stroke onset. Seizures were diagnosed and classified by International League Against Epilepsy (ILAE) seizure classification.[2] Diagnosis of seizures was made clinically by a trained neurology consultant. Demographics, variables, types, frequency of the seizures, poststroke day on which seizure developed, and radiological findings concerning the location of stroke were noted on predesigned proforma.

The sample size calculated was 281 through nonprobability consecutive sampling.

Statistical analysis

The data were analyzed using SPSS version 20.0 (IBM Corp., Armonk, NY, USA). Quantitative variables such as age and poststroke day on which seizure developed were measured by mean and standard deviation. The qualitative variables such as gender and radiological findings regarding the type and location of stroke were presented in frequency and percentages. The effect modification of outcome variable (frequency of seizure) due to age, gender, location of stroke, and duration of stroke was dealt with stratification of these variables. Poststratification Chi-square test with a P value significance of < 0.05 was applied. The biases were controlled through strict enforcement of inclusion and exclusion criteria.


  Results Top


Total 281 patients with ischemic stroke were enrolled. The mean age of the sample was 48.41 ± 8.730 years. Male patients were 181 (64.4%) and 100 (35.6%) were female.

Early-onset seizures were noted in 22 patients (7.8%). Semiology of seizure observed in the study was generalized tonic–clonic in 163 patients (58%), focal in 83 (29.5%), and secondary generalized in 35 (12.5%). Status epilepticus was not reported in any of our cases. The seizures occurred on a mean of 7.38 ± 2.881 poststroke days. The location of ischemic stroke on magnetic resonance imaging (MRI) brain was frontal in 70 patients (24.9%), parietal in 116 (41.3%), temporal in 68 (24.2%), and occipital in 27 (9.6%).

The frequencies of age groups, gender, localization (on MRI brain), type of seizures, and poststroke day on which seizure occurred were calculated. The results are presented in [Table 1], [Table 2], [Table 3], [Table 4].
Table 1: Demographic characteristics of patients enrolled in the study

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Table 2: Frequency and poststroke day of early-onset seizures (n=281)

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Table 3: Ischemic stroke location on magnetic resonance imaging brain (n=281)

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Table 4: Semiology of early-onset poststroke seizures (n=281)

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  Discussion Top


Seizure occurrence immediately after stroke is associated with poor prognosis and worsening functional outcomes.[2],[3] Chances of acute symptomatic seizures are higher in large cortical stroke and in hemorrhagic stroke.[4] Seizures occur secondary to metabolic derangements, neuronal injury, and excessive glutamate production in response to ischemia.[5] Whereas, late-onset seizure is thought to be because of gliotic changes and scar formation in meninges and cortex.[5]

Early poststroke seizures can present as focal, generalized tonic–clonic, and focal to bilateral tonic–clonic seizures.[6] Thereby, it is worthwhile to perform electroencephalogram (EEG) in all patients.[7],[8] The reported incidence ranges from 2.2% to 33% in previous studies.[9]

Acute management of seizure is mandatory in patients with acute ischemic stroke since continual seizure activity can further augment the ischemia, lessens the penumbra,[10] and can worsen functional outcome. However, long-term antiepileptic drugs are rarely required because of low recurrence rates.[11]

Seizure stroke study determined the frequency of seizures in ischemic and hemorrhagic stroke independently.[5] They reported that early seizures occurred in 8.6% of patients with cerebral infarction.[5] Our results showed that 7.8% had early-onset seizures after ischemic stroke. Qazi et al. observed poststroke seizures within 14 days in 7.1%, and another study done in Pakistan reported seizures in 9%.[12] The results of our study are analogous to these studies.

The mean age of the sample was 48.41 ± 8.73 (range: 25–60 years). In contrast, the mean age reported in Qazi et al. and Khealani et al. studies was 55.38 ± 5.66. Preponderance of seizures was noticed in males (4.27%) (P = 0.314). Qazi et al.[12] also reported increased frequency in male patients compared to females.

The majority of seizures in our research occurred within 7 days of stroke onset (n = 13). Previous authors have reported the highest incidence within 7 days of stroke onset as well, and 90% of seizures occur in the first 24 h of stroke.[5],[13],[14]

Potential risk factors for poststroke seizures include hemorrhagic stroke type, cortical involvement, supratentorial infarct, and high National Institutes of Health Stroke Scale.[15] A stroke involving the parietal lobe (middle cerebral artery) had a greater chance of seizures (41.3%) in our study. The second most common (24.9%) territory was frontal (anterior cerebral artery). A study done by Bryndziar et al. showed that the location and territory of stroke were not related to poststroke seizures (P > 0.05).[16] Similarly, no difference was observed in different TOAST subtypes with early seizures.[16] Correspondingly, in our research, no association between the lobe involved in the MRI brain and the frequency of early-onset poststroke seizure was established (P = 0.723).

In this study, generalized tonic–clonic seizures (58%) were the most frequent seizure type observed, followed by focal seizures (29.5%). Status epilepticus and refractory seizures were not reported in any of our cases. Conversely, a study done by Giroud et al.[17] and another study by Gupta et al.[18] reported simple partial seizure (61%) and partial (57%) seizure as the most frequent type.


  Conclusion Top


In conclusion, 7.8% of patients with acute ischemic stroke exhibited early-onset poststroke seizures. Prompt recognition and diagnosis can lessen morbidity and mortality associated with it.

Limitations of the study

An EEG was not ordered in any of the patients presenting with postischemic seizures. Patients were not followed after discharge from the hospital; therefore, prognosis and disability were not determined in our study. Furthermore, sample size compared to other studies is not enough to generalize these results to the whole population. Further work is needed to determine the frequency which is representative of our population.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ranganathan LN, Subramanian S, Ramamurthy G, Arun Shivaraman MM. Early post-stroke seizures with first-ever stroke. Neurol India 2018;66:949-51.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Adams HP Jr., Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993;24:35-41.  Back to cited text no. 2
    
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Kilpatrick CJ, Davis SM, Tress BM, Rossiter SC, Hopper JL, Vandendriesen ML. Epileptic seizures in acute stroke. Arch Neurol 1990;47:157-60.  Back to cited text no. 3
    
4.
Back T, Ginsberg MD, Dietrich WD, Watson BD. Induction of spreading depression in the ischemic hemisphere following experimental middle cerebral artery occlusion: Effect on infarct morphology. J Cereb Blood Flow Metab 1996;16:202-13.  Back to cited text no. 4
    
5.
Bladin CF, Alexandrov AV, Bellavance A, Bornstein N, Chambers B, Coté R, et al. Seizures after stroke: A prospective multicenter study. Arch Neurol 2000;57:1617-22.  Back to cited text no. 5
    
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Mohamed C, Kissani N. Early seizures in acute stroke. Pan Afr Med J 2015;20:136.  Back to cited text no. 6
    
7.
Macdonell RA, Donnan GA, Bladin PF, Berkovic SF, Wriedt CH. The electroencephalogram and acute ischemic stroke. Distinguishing cortical from lacunar infarction. Arch Neurol 1988;45:520-4.  Back to cited text no. 7
    
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Naess H, Nyland HI, Thomassen L, Aarseth J, Myhr KM. Long-term outcome of cerebral infarction in young adults. Acta Neurol Scand 2004;110:107-12.  Back to cited text no. 8
    
9.
Xu MY. Poststroke seizure: Optimising its management. Stroke Vasc Neurol 2019;4:48-56.  Back to cited text no. 9
    
10.
Karhunen H, Jolkkonen J, Sivenius J, Pitkänen A. Epileptogenesis after experimental focal cerebral ischemia. Neurochem Res 2005;30:1529-42.  Back to cited text no. 10
    
11.
Marrero C, Díez E, Iváñez V, Barreiro P. Early and late epileptic crisis following cerebral hemisphere ischemia. Rev Neurol 1998;27:676-81.  Back to cited text no. 11
    
12.
Qazi TR, Siddiqui AI, Lakhair MA, Mahesar SA. Frequency of early seizures in patients of acute ischemic stroke. J Liaquat Uni Med Health Sci 2016;15:143-6.  Back to cited text no. 12
    
13.
Alberti A, Paciaroni M, Caso V, Venti M, Palmerini F, Agnelli G. Early seizures in patients with acute stroke: Frequency, predictive factors, and effect on clinical outcome. Vasc Health Risk Manag 2008;4:715-20.  Back to cited text no. 13
    
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Procaccianti G, Zaniboni A, Rondelli F, Crisci M, Sacquegna T. Seizures in acute stroke: Incidence, risk factors and prognosis. Neuroepidemiology 2012;39:45-50.  Back to cited text no. 14
    
15.
Tanaka T, Ihara M. Post-stroke epilepsy. Neurochem Int 2017;107:219-28.  Back to cited text no. 15
    
16.
Bryndziar T, Sedova P, Kramer NM, Mandrekar J, Mikulik R, Brown RD Jr., et al. Seizures following ischemic stroke: Frequency of occurrence and impact on outcome in a long-term population-based study. J Stroke Cerebrovasc Dis 2016;25:150-6.  Back to cited text no. 16
    
17.
Giroud M, Gras P, Fayolle H, André N, Soichot P, Dumas R. Early seizures after acute stroke: A study of 1,640 cases. Epilepsia 1994;35:959-64.  Back to cited text no. 17
    
18.
Gupta SR, Naheedy MH, Elias D, Rubino FA. Postinfarction seizures. A clinical study. Stroke 1988;19:1477-81.  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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Introduction
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