High Risk of Seizures and Epilepsy after Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke

Abstract

Background: Decompressive hemicraniectomy (DHC) is a life-saving procedure for treatment of large malignant middle cerebral artery (MCA) strokes. Post-stroke epilepsy is an additional burden for these patients, but its incidence and the risk factors for its development have been poorly investigated. Objective: To report the prevalence and risk factors for post-stroke seizures and post-stroke epilepsy after DHC for treatment of large malignant MCA strokes in a cohort of 36 patients. Methods: In a retrospective cohort study of 36 patients we report the timing and incidence of post-stroke epilepsy. We analyzed if age, sex, vascular risk factors, side of ischemia, reperfusion therapy, stroke etiology, extension of stroke, hemorrhagic transformation, ECASS scores, National Institutes of Health Stroke Scale (NIHSS) scores, or modified Rankin scores were risk factors for seizure or epilepsy after DHC for treatment of large MCA strokes. Results: The mean patient follow-up time was 1,086 days (SD = 1,172). Out of 36 patients, 9 (25.0%) died before being discharged. After 1 year, a total of 11 patients (30.6%) had died, but 22 (61.1%) of them had a modified Rankin score ≤4. Thirteen patients (36.1%) developed seizures within the first week after stroke. Seizures occurred in 22 (61.1%) of 36 patients (95% CI = 45.17–77.03%). Out of 34 patients who survived the acute period, 19 (55.9%) developed epilepsy after MCA infarcts and DHC (95% CI = 39.21–72.59%). In this study, no significant differences were observed between the patients who developed seizures or epilepsy and those who remained free of seizures or epilepsy regarding age, sex, side of stroke, presence of the clinical risk factors studied, hemorrhagic transformation, time of craniectomy, and Rankin score after 1 year of stroke. Conclusion: The incidence of seizures and epilepsy after malignant MCA infarcts submitted to DHC might be very high. Seizure might occur precociously in patients who are not submitted to anticonvulsant prophylaxis. The large stroke volume and the large cortical ischemic area seem to be the main risk factors for seizure or epilepsy development in this subtype of stroke.

Outcome and predictive factors in post-stroke seizures: A retrospective case-control study

“…This is relevant when determining when and how long to maintain ASD therapy. Studies have previously shown that cortical infarcts particularly in the middle cerebral artery territory influence the risk of PSS recurrence [31,32]. This agrees with our results demonstrating a higher incidence of anterior circulation infarcts in patients with PSS.…”

“…A subset of ischemic stroke patients who underwent decompressive hemicraniectomy for large middle cerebral infarctions was assessed. Over 1086 days, seizures occurred in 22 of 36 patients (61.1%), demonstrating a very high incidence of PSS in this population [31]. In our study, a small number of patients were operated on and no difference was found between those with and without PSS.…”

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

“…In the DECIMAL trial (DEcompressive Craniectomy In MALignant MCA Stroke), authors observed greater risk of seizures in patients with malignant middle cerebral artery stroke, independently of decompressive craniectomy, being 6 of 15 survivors (40%) with craniectomy and 2 of 4 survivors (50%) without decompressive hemicraniectomy (81). We have previously observed similar rates after decompressive craniectomy (82). Our data showed that initial NIHSS scores correlate with seizures or epilepsy development.…”

Complications of Decompressive Craniectomy

“…In another study, Brondani et al reported the prevalence of seizures in 61% (21 out of 36) of the patients with malignant MCA infarction undergoing DC. Furthermore, 59% (19 out of 34) patients developed epilepsy ( 33 ). Although a non-significant difference existed between TBI patients with or without seizures (incidence of 10.8%), the hospital stay prolonged significantly in the former group ( 35 ).…”