Association between different acute stroke therapies and development of post stroke seizures

Abstract

BackgroundEpilepsy is a major complication of stroke. We aimed to establish whether there is an association between intravenous thrombolysis, intra-arterial thrombolysis and post stroke seizure (PSS) development. Improved understanding of the relationship between reperfusion therapies and seizure development may improve post-stroke monitoring and follow-up.MethodsThis was a retrospective, multicentre cohort study conducted at the Royal Melbourne Hospital and Jingling Hospital Nanjing. We included patients with anterior circulation ischemic stroke admitted 2008–2015. Patients were divided into four treatment groups 1. IV-tPA only, 2. Intra-arterial therapies (IAT) only, 3. IAT + IV-tPA and 4. stroke unit care only (i.e. no IV-tPA or IAT). To assess the association between type of reperfusion treatment and seizure incidence we used multivariable logistic regression models adjusted for age, stroke severity, 3-month functional outcome and prognostic factors.ResultsThere were 1375 stroke unit care-only patients, of whom 28 (2%) developed PSS. There were 363 patients who received only IV-tPA, of whom 21 (5.8%) developed PSS. There were 93 patients who received IAT only, of whom 12 (12.9%) developed PSS and 112 that received both IV-tPA + IAT, of which 5 (4.5%) developed PSS. All reperfusion treatments were associated with seizure development compared to stroke unit care-only patients: IV-tPA only adjusted odds ratio (aOR) 3.7, 95%CI 1.8–7.4, p < 0.0001; IAT aOR 5.5, 95%CI 2.1–14.3, p < 0.0001, IAT + IV-tPA aOR 3.4, 95% CI 0.98–11.8, p = 0.05. These aORs did not differ significantly between treatment groups (IV-tPA + IAT versus IV-tPA p = 0.89, IV-tPA + IAT versus IAT, p = 0.44).ConclusionsPatients receiving thrombolytic or intra-arterial reperfusion therapies for acute ischemic stroke are at higher risk of epilepsy and may benefit from longer follow-up. No evidence for an additive or synergistic effect of treatment modality on seizure development was found.Electronic supplementary materialThe online version of this article (10.1186/s12883-018-1064-x) contains supplementary material, which is available to authorized users.

Risk Factors for Epilepsy After Thrombolysis for Ischemic Stroke: A Cohort Study

“…Among the mechanisms involved in the effect of rt-PA in post-stroke increasing seizure risk are sudden change in cerebral perfusion which might be associated with a cascade of inflammatory responses, the development of the reperfusion syndrome and subsequent seizures and post-stroke epilepsy. In spite that rt-PA might show some toxicity, the similar rates of occurrence of poststroke seizures between patients treated only with IA with those treated with IA plus rt-PA suggest that reperfusion, per se, might be the responsible for the increase of seizure frequency after rt-PA therapy (71).…”

“…However, other authors have reported an increase in seizures incidence during the acute period of stroke after rt-PA (31,38). Moreover, Naylor et al reported that the risk of seizures after rt-PA extends further than the acute stage of stroke, and might occur over a 24-months period (71). Among the mechanisms involved in the effect of rt-PA in post-stroke increasing seizure risk are sudden change in cerebral perfusion which might be associated with a cascade of inflammatory responses, the development of the reperfusion syndrome and subsequent seizures and post-stroke epilepsy.…”

Stroke‐related epilepsy

“…Patients receiving thrombolytic or intra‐arterial therapies for acute stroke were found to be at higher risk of epilepsy in another study . Notably, the risk of acute seizures was not associated with hemorrhagic transformation or recanalization and reperfusion injury, but it was related to the severity of stroke and the extent of cortical involvement . Several mechanisms have been postulated for this association, including neurotoxicity and a possible epileptogenic effect of rtPA.…”

“…A case‐control study identified rtPA as an independent risk factor for ESs . Patients receiving thrombolytic or intra‐arterial therapies for acute stroke were found to be at higher risk of epilepsy in another study . Notably, the risk of acute seizures was not associated with hemorrhagic transformation or recanalization and reperfusion injury, but it was related to the severity of stroke and the extent of cortical involvement .…”

Acute symptomatic seizures and epilepsy after mechanical thrombectomy

“…Reported rates of acute symptomatic seizures (seizures within one week of stroke) in thrombolysis-treated patients vary from approximately 1% to 15% [6][7][8][9]. In three relatively recent studies of thrombolysis-treated cohorts, PSE (seizures occurring >1 week after stroke) was reported in 5.8%-16.7% [6,10,11]. After thrombectomy, acute symptomatic seizures have been described in 2.4 % [12].…”