This case report describes a 72-year old man who presented with two seizures. He had a history of stroke 9 months prior that caused left hemiplegia. MRI and CT scans confirmed an old right middle cerebral artery infarct. He was diagnosed with post-stroke epilepsy. Anti-epileptic medication was started and he was discharged seizure-free after 2 days. Stroke is a common cause of epilepsy in older adults, with seizures occurring in about 9% of post-stroke patients. Newer anti-epileptic drugs like lamotrigine are preferred for post-stroke epilepsy due to fewer side effects and interactions compared to older drugs.

1. POST STROKE
EPILEPSY
DR SUDHIR KUMAR MD DM
SENIOR CONSULTANT NEUROLOGIST
APOLLO HOSPITALS, HYDERABAD

2. CASE REPORT
• 72-year old gentleman,
• Presented with two episodes of seizures within the
past 30 minutes,
• Both were left focal onset motor seizures with
secondary generalization.
• There was no past history of epilepsy.

3. • There was a past history of stroke about nine
months ago, when he suffered left hemiplegia. He
had made partial recovery with physiotherapy and
was independent for activities of daily living.
• He was a known diabetic and hypertensive on
appropriate medications.
• He was also on aspirin 150 mg and rosuvastatin
10 mg once daily.

4. • On examination, he was in post-ictal state,
• BP was 130/80 mmHg
• He had mild left spastic hemiparesis.

5. MRI BRAIN (9 months ago)
ACUTE RIGHT MCA TERRITORY INFARCT

6. CT BRAIN (at admission now)
OLD RIGHT MCA TERRIOTRY INFARCT WITH GLIOSIS

7. DIAGNOSIS
• A diagnosis of old right middle cerebral artery
stroke with post-stroke epilepsy was made.
• He was admitted to the ICU,
• Anti-epileptic medication was started.

8. Management of the case
• IV Lorazepam 2 mg was given in the ER,
• Lamotrigine was started at a dose of 25 mg once
daily and gradually increased to a dose of 100 mg
twice daily,
• Patient remained seizure free and was discharged
in 2 days,
• He was regularly followed up for six months, and
there was no recurrence of seizures.

9. POST STROKE EPILEPSY-
Epidemiology
• Stroke is the most common identifiable cause of
epilepsy in people above 35 years of age.
• In elderly, stroke is the cause of seizures in >50%
of cases, where a cause is identified.
• Seizures occur in about 9% of patients after
stroke; however, recurrent seizures occur in
only 2-3% of cases,
• Seizures occur more commonly after
hemorrhagic than ischemic stroke.

10. Epidemiology (2)
• Cortical strokes are more likely to cause post-
stroke seizures,
• Strokes involving multiple lobes are more likely to
cause seizures than stroke involving single lobe,
• Hemorrhagic stroke involving cortex led to
seizures in 54%, basal ganglia in 19% and
thalamus-none.
• Involvement of parietal or temporal lobe or
caudate nucleus predicted higher risk of seizures.

11. POST-STROKE SEIZURES-
Classification
• Early post-stroke seizures: occur within two
weeks of stroke onset;
• Late post-stroke seizures: occur after two weeks
of stroke onset.

12. EARLY POST-STROKE
SEIZURES
• Most seizures occur within 24 hours of stroke
onset,
• Causative mechanisms: accumulation of
intracellular calcium and sodium; glutamate
excitotoxicity; local ischemia (hippocampus is
sensitive to ischemia); global hypoperfusion,
metabolic derangements.

13. LATE POST-STROKE
SEIZURES
• Persistent changes in neuronal excitability occur,
• Gliotic scarring is seen in most cases of late-onset
seizures.
• 90% of patients with late-onset seizures may
develop epilepsy (as compared to about 35% with
early onset seizures) in patients with ischemic
stroke.
• These figures are similar in hemorrhagic stroke
(93% versus 29%)

14. SEMIOLOGY
• Most post-stroke seizures are simple partial
(61%), followed by secondarily generalized
seizures (28%);
• Early-onset seizures are more likely to be partial,
whereas late-onset seizures are likely to be
secondarily generalized.
• 9% patients can develop status epilepticus,

15. ANTI-EPILEPTIC DRUG
THERAPY (1)
• Usually, no prophylactic AED is needed in patients
with stroke without seizures,
• When seizures occur, most neurologists
administer AEDs; however, long term AED may
not be needed in most patients with early post-
stroke seizures,
• AEDs are needed for patients with late post-stroke
seizures. Epidemiology

16. ANTI-EPILEPTIC DRUG
THERAPY (2)
• Monotherapy is sufficient is patients with post-
stroke seizures (about 88% patients achieve good
seizure control with a single AED),
• Carbamazepine or oxcarbazepine are usually
preferred as most post-stroke seizures are partial
in nature
• There is a risk of hyponatremia in elderly with CBZ
or OXC.

17. LAMOTRIGINE VS CBZ in
elderly
• UK Lamotrigine elderly study group, 1999 (Epilepsy
Research)
• Multi-center, double-blind, randomized trial
involving 150 elderly patients (mean age 77
years), with newly diagnosed epilepsy
• Treated with LTG or CBZ, and followed up for 24
weeks,

18. LAMOTRIGINE VS CBZ in
elderly (2)
Lamotrigine Carbamazepine
Drop out due to AEs 18% 42%
Skin rash 3% 19%
Drowsiness 12% 29%
Seizure freedom (last
16 weeks)
39% 21% (p=0.027)
Compliance 71% 42% (p<0.001)
Hazard ratio for
withdrawal
2.4

19. RECOMMENDATIONS
Newer AEDs such as Lamotrigine and
levetiracetam are preferred because of:
• Higher rate of long-term seizure-free periods,
• Improved safety profile,
• Fewer interactions with other drugs, especially
anticoagulant ones.
Monotherapy is sufficient in most cases.

20. RECOMMENDATIONS (2)
Older AEDs such as CBZ, OXC, DPH are not
preferred:
• Harmful effects on recovery from stroke,
• Impaired bone health,
• Negative effects on cognition,
• Risk of hyponatremia,
• Increased chances of drug interactions

21. THANK YOU
drsudhirkumar@yahoo.com