This document provides guidelines from the European Stroke Organisation for the management of post-stroke seizures and epilepsy. It summarizes that seizures occurring within 7 days of a stroke are considered acute symptomatic seizures, while those occurring after 7 days are considered unprovoked seizures. The guidelines were developed by reviewing randomized controlled trials and observational studies to make recommendations, though the evidence for most was very low. The guidelines provide some weak recommendations for prevention and management of post-stroke seizures, but large randomized trials are still needed to better guide treatment.
Techniques in Neurosurgery & Neurology
Authors:
Irina Gontschar1 and Igor Prudyvus2
1Student, Health Information Management and Insurance Billing Program by the EVANS Community Adult School, Los Angeles, USA
2Chief Application Support Analysts, EPAM Systems, Minsk, Belarus
Abstract
Introduction: The purpose of the study is to identify the independent clinical predictors of the evolving ischemic stroke (EIS) according to the tree-structured model.
Methods and Materials: The objects of the study were 1421 patients with ischemic stroke (IS), hospitalized within 48 hours from the development of the initial symptoms. Patients with IS were admitted to the 5th Minsk City Clinical Hospital and the Minsk Emergency Hospital (Belarus) in 2002-2014 years. Evolving clinical course of the stroke is defined as an increase in the severity of neurological deficit by 2 or more points on the NIHSS scale or the death of the patient during the first seven days of hospitalization. The research is characterized due to the prospective-data-collection, and the retrospective evaluation design. The statistical method of decision trees and an algorithm of the conditional inference trees were used to create the prognostic model of EIS. Statistical data analysis was carried out applying the software packages of R V.3.2.5 and IBM SPSS Statistics 26.0.
Results: The rate of EIS reached 30%. The patients with EIS were 72.6±10.2 years old, patients without EIS - 68.1±11.3 years; p = 0.005. Previously, 22 clinical, demographic, laboratory variables accommodated in the computer database were included in the conditional inference trees statistical algorithm. The prognostic statistical model of EIS has been constructed. The following independent predictors of evolving IS were identified: the stroke subtype according to the Oxford Community Stroke Project classification, the serum urea level, and red blood cell number in the total blood count. The accuracy of the statistical model reaches 0.77 (95% CI: 0.75; 0.80), the sensitivity is 0.52, the specificity - 0.88, PPV - 0.66, and NPV - 0.81; p < 0.001.
Conclusion: The tree-structural model allowed us to identify the independent clinical predictors of EIS.
Keywords: Cerebral infarction, Clinical characteristics, Clinical course, Conditional inference trees algorithm, Decision tree, Evolving ischemic stroke, Model, Predictor, Prognosis, Stroke deterioration
In this multiethnic, elderly, population-based cohort, PFO detected with transthoracic echocardiography and agitated saline was not associated with self-reported migraine. The causal relationship between PFO and migraine remains uncertain, and the role of PFO closure among unselected patients with migraine remains questionable
Epilepsy can occur after stroke, and is more common in elderly population. This talk looks at classification, epidemiology, pathogenesis, clinical presentation and treatment of post-stroke seizures and epilepsy. The risk factors for the development of post-stroke seizures have also been looked at.
Techniques in Neurosurgery & Neurology
Authors:
Irina Gontschar1 and Igor Prudyvus2
1Student, Health Information Management and Insurance Billing Program by the EVANS Community Adult School, Los Angeles, USA
2Chief Application Support Analysts, EPAM Systems, Minsk, Belarus
Abstract
Introduction: The purpose of the study is to identify the independent clinical predictors of the evolving ischemic stroke (EIS) according to the tree-structured model.
Methods and Materials: The objects of the study were 1421 patients with ischemic stroke (IS), hospitalized within 48 hours from the development of the initial symptoms. Patients with IS were admitted to the 5th Minsk City Clinical Hospital and the Minsk Emergency Hospital (Belarus) in 2002-2014 years. Evolving clinical course of the stroke is defined as an increase in the severity of neurological deficit by 2 or more points on the NIHSS scale or the death of the patient during the first seven days of hospitalization. The research is characterized due to the prospective-data-collection, and the retrospective evaluation design. The statistical method of decision trees and an algorithm of the conditional inference trees were used to create the prognostic model of EIS. Statistical data analysis was carried out applying the software packages of R V.3.2.5 and IBM SPSS Statistics 26.0.
Results: The rate of EIS reached 30%. The patients with EIS were 72.6±10.2 years old, patients without EIS - 68.1±11.3 years; p = 0.005. Previously, 22 clinical, demographic, laboratory variables accommodated in the computer database were included in the conditional inference trees statistical algorithm. The prognostic statistical model of EIS has been constructed. The following independent predictors of evolving IS were identified: the stroke subtype according to the Oxford Community Stroke Project classification, the serum urea level, and red blood cell number in the total blood count. The accuracy of the statistical model reaches 0.77 (95% CI: 0.75; 0.80), the sensitivity is 0.52, the specificity - 0.88, PPV - 0.66, and NPV - 0.81; p < 0.001.
Conclusion: The tree-structural model allowed us to identify the independent clinical predictors of EIS.
Keywords: Cerebral infarction, Clinical characteristics, Clinical course, Conditional inference trees algorithm, Decision tree, Evolving ischemic stroke, Model, Predictor, Prognosis, Stroke deterioration
In this multiethnic, elderly, population-based cohort, PFO detected with transthoracic echocardiography and agitated saline was not associated with self-reported migraine. The causal relationship between PFO and migraine remains uncertain, and the role of PFO closure among unselected patients with migraine remains questionable
Epilepsy can occur after stroke, and is more common in elderly population. This talk looks at classification, epidemiology, pathogenesis, clinical presentation and treatment of post-stroke seizures and epilepsy. The risk factors for the development of post-stroke seizures have also been looked at.
Cryptogenic stroke and PFO have always been a controversial topic with no closure trial in the past showing significant benefit from closing the PFO in preventing the recurrent stroke. Also thought to be due to imperfect definition of cryptogenic stroke which is evolving with drop in the fraction of patients from 20-40% in the past to very fewer numbers due to increased understanding of the mechanisms involved in acute stroke. Recent trials REDUCE and CLOSE targeted the niche population of PFO with moderate to large shunt and atrial septal aneurysm and showed benefit of closing PFO compared to the antiplatelet therapy alone but with the risk of A.fib, device and procedure related complications. This presentation is made in the Cerebrovascular center weekly conference at the Cleveland Clinic with my perspective after these current trials.
RCVS is usually a benign cerebral vascular dysregulation induced clinico-radiological syndrome presents typically with recurrent thunderclap headache with or without ischemic/hemorrhagic stroke or cerebral edema with vasoconstriction. Various risk factors are responsible for this syndrome.
Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The goal of the study was to identify the most significant prognostic clinical criteria for the survival of patients with ischemic stroke (IS) within 1 year of observation.
Methods and Materials: The object of the clinical prospective study was 1421 patients with IS hospitalized in 2002-2015 in the neurological (stroke) departments of the 5th Minsk City Clinical Hospital and the Minsk Emergency Hospital. Analyzing the obtained data, we adhered to the prospective-specimen-collection, retrospective evaluation design of the study. The primary endpoint of the study was the patient's death from any reason within one year of the development of IS. Information on poststroke all-cause mortality was obtained through linkages to the official source - the centralized archive of deaths of residents of the city of Minsk. Patients without a confirmed death date were censored at the date last known alive. All patients that were alive at one year are assumed to be censored at that time. The collection of clinical, demographic, neuroimaging, laboratory data, as well as the final determination of the stroke outcome, was performed blindly with respect to survival data.
Results: To build the model, 22 multivariate clinical indicators were used that demonstrated the relationship with post-stroke survival at the stage of preliminary data analysis: stroke subtype according the Oxfordshire Community Stroke Project, age, gender, the severity of the neurological deficit according to the NIHSS scale at hospitalization, previous stroke or TIA, the presence of arterial hypertension, atrial fibrillation, myocardial atherosclerosis, congestive heart failure, diabetes mellitus, peripheral arterial diseases, alcohol abuse, level of creatinine, glucose, urea, potassium, sodium in blood, amount of hemoglobin, erythrocytes and leukocytes on the 1st day of treatment, the level of systolic and diastolic blood pressure in the hospital admission department.
In the construction of a survival decision tree of patients with IS, of the 22 initially embedded parameters, only 6 independent predictors were finally included in the prognostic model: the stroke subtype according to the OCSP, the presence of a lacunar infarction, the severity of neurologic deficit at hospitalization according NIHSS, level of urea and glucose in the blood, and the presence of congestive heart failure.
Mini Overview of a Prime Interoceptor: From Basics to Role in Pathologiesasclepiuspdfs
Frequently overlooked is arguably the most important sensor of the organism’s internal environment, the carotid body (CB). In human subjects this structure alone warns the organism when the partial pressure of oxygen in the arterial blood is becoming insufficient to meet the organism’s needs. But the structure is also stimulated by hypercarbia, glucopenia, acidosis, increases in temperature and osmolarity of the arterial blood. Reflex responses generated by a stimulated CB are found in the respiratory, cardiovascular, renal, and endocrine systems. Recent widespread pathologies also involve the CB. A simple, brief overview of this important structure could prove helpful for biomedical investigators focused on other important biomedical issues.
Obstructive Sleep Apnoea (OSA) and Cerebrovascular Accidents (CVA) are common disorders in general population and share many common risk factors as age, gender, family history and obesity. However some of the strongest pathophysiological triggers for stroke are hypertension, atrial arrhythmias and atherosclerosis. Untreated OSA also contributes to these issues. Untreated sleep disorder breathing (SDB) such as OSA can lead to strokes, and strokes in the absence of prior history of OSA, might lead to SDB including Central Sleep Apnoea (CSA) and Obstructive Sleep Apnoea (OSA). Therefore it is of paramount importance to evaluate to the association between SDB and stroke and determine therapeutic approaches to treat SDB in such population.
Cryptogenic stroke and PFO have always been a controversial topic with no closure trial in the past showing significant benefit from closing the PFO in preventing the recurrent stroke. Also thought to be due to imperfect definition of cryptogenic stroke which is evolving with drop in the fraction of patients from 20-40% in the past to very fewer numbers due to increased understanding of the mechanisms involved in acute stroke. Recent trials REDUCE and CLOSE targeted the niche population of PFO with moderate to large shunt and atrial septal aneurysm and showed benefit of closing PFO compared to the antiplatelet therapy alone but with the risk of A.fib, device and procedure related complications. This presentation is made in the Cerebrovascular center weekly conference at the Cleveland Clinic with my perspective after these current trials.
RCVS is usually a benign cerebral vascular dysregulation induced clinico-radiological syndrome presents typically with recurrent thunderclap headache with or without ischemic/hemorrhagic stroke or cerebral edema with vasoconstriction. Various risk factors are responsible for this syndrome.
Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The goal of the study was to identify the most significant prognostic clinical criteria for the survival of patients with ischemic stroke (IS) within 1 year of observation.
Methods and Materials: The object of the clinical prospective study was 1421 patients with IS hospitalized in 2002-2015 in the neurological (stroke) departments of the 5th Minsk City Clinical Hospital and the Minsk Emergency Hospital. Analyzing the obtained data, we adhered to the prospective-specimen-collection, retrospective evaluation design of the study. The primary endpoint of the study was the patient's death from any reason within one year of the development of IS. Information on poststroke all-cause mortality was obtained through linkages to the official source - the centralized archive of deaths of residents of the city of Minsk. Patients without a confirmed death date were censored at the date last known alive. All patients that were alive at one year are assumed to be censored at that time. The collection of clinical, demographic, neuroimaging, laboratory data, as well as the final determination of the stroke outcome, was performed blindly with respect to survival data.
Results: To build the model, 22 multivariate clinical indicators were used that demonstrated the relationship with post-stroke survival at the stage of preliminary data analysis: stroke subtype according the Oxfordshire Community Stroke Project, age, gender, the severity of the neurological deficit according to the NIHSS scale at hospitalization, previous stroke or TIA, the presence of arterial hypertension, atrial fibrillation, myocardial atherosclerosis, congestive heart failure, diabetes mellitus, peripheral arterial diseases, alcohol abuse, level of creatinine, glucose, urea, potassium, sodium in blood, amount of hemoglobin, erythrocytes and leukocytes on the 1st day of treatment, the level of systolic and diastolic blood pressure in the hospital admission department.
In the construction of a survival decision tree of patients with IS, of the 22 initially embedded parameters, only 6 independent predictors were finally included in the prognostic model: the stroke subtype according to the OCSP, the presence of a lacunar infarction, the severity of neurologic deficit at hospitalization according NIHSS, level of urea and glucose in the blood, and the presence of congestive heart failure.
Mini Overview of a Prime Interoceptor: From Basics to Role in Pathologiesasclepiuspdfs
Frequently overlooked is arguably the most important sensor of the organism’s internal environment, the carotid body (CB). In human subjects this structure alone warns the organism when the partial pressure of oxygen in the arterial blood is becoming insufficient to meet the organism’s needs. But the structure is also stimulated by hypercarbia, glucopenia, acidosis, increases in temperature and osmolarity of the arterial blood. Reflex responses generated by a stimulated CB are found in the respiratory, cardiovascular, renal, and endocrine systems. Recent widespread pathologies also involve the CB. A simple, brief overview of this important structure could prove helpful for biomedical investigators focused on other important biomedical issues.
Obstructive Sleep Apnoea (OSA) and Cerebrovascular Accidents (CVA) are common disorders in general population and share many common risk factors as age, gender, family history and obesity. However some of the strongest pathophysiological triggers for stroke are hypertension, atrial arrhythmias and atherosclerosis. Untreated OSA also contributes to these issues. Untreated sleep disorder breathing (SDB) such as OSA can lead to strokes, and strokes in the absence of prior history of OSA, might lead to SDB including Central Sleep Apnoea (CSA) and Obstructive Sleep Apnoea (OSA). Therefore it is of paramount importance to evaluate to the association between SDB and stroke and determine therapeutic approaches to treat SDB in such population.
The Prevalence and Prognostic Value of Neuroimaging Abnormalities in the Acut...CrimsonPublishersTNN
The Prevalence and Prognostic Value of Neuroimaging Abnormalities in the Acute Phase of Sepsis-Associated Encephalopathy by Keenan A Walker in Techniques in Neurosurgery & Neurology
Global Medical Cures™ | STROKE- Challenges, Progress & Promise
DISCLAIMER-
Global Medical Cures™ does not offer any medical advice, diagnosis, treatment or recommendations. Only your healthcare provider/physician can offer you information and recommendations for you to decide about your healthcare choices.
Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The purpose of the study is to provide information about the database of 1421 adult patients with acute ischemic stroke (IS) developing ≤ 48 hours before admitting, research methods, study protocol, and clinical predictors of the evolving stroke course (EIS).
Methods and Materials: EIS outlined as an increase of NIHSS ≥ 2 points within seven days or in-hospital lethal outcome. Clinical, demographic, instrumental, laboratory data acquisition, as well as the IS course variant and the functional outcome assessment, were carried out prospectively. Statistical analyses were performed using R V.3.2.5 statistical package software and IBM SPSS Statistics 26.0.
Results: The incidence of EIS reached 30.0%. The average age of patients with EIS was 72.6±10.2 years, compare the age of patients without EIS - 68.1±11.3 years; p = 0.005. Female sex increased the odds of EIS (OR, 1.36; 95% CI 1.08-1.73). Total anterior carotid stroke (OR, 7.78; 95% CI 5.91-10.23), the initial NIHSS score > 14 points (OR, 3.74; 95% CI 2.83-4.94), and the right anterior circulation was also associated with EIS (OR, 1.30; 95% CI 1.02-1.66). The odds of EIS were significantly higher in the presence of diabetes mellitus (OR, 1.29; 95% CI 1.01-1.66), cerebral artery stenosis ≥ 70% (OR, 1.96; 95% CI 1.30-2.93), atrial fibrillation (OR, 1.89; 95% CI 1.51-2.39), congestive heart failure (OR, 1.90; 95% CI 1.51-2.39), and peripheral artery disease (OR, 1.69; 95% CI 1.27-2.25). Respiratory (OR, 2.82; 95% CI 2.22-3.59), gastrointestinal (OR, 1.34; 95% CI 1.05-1.70), and urologic diseases (OR, 2.10; 95% CI 1.65-2.66), stroke-associated infection (OR, 3.47; 95% CI 2.09-5.76), and gradual development of initial IS symptoms before admitting increased the odds of progression of the neurological deficit during treatment (OR, 2.37; 95% CI 1.78-3.15)were associated with the evolving clinical course of IS. The patients with the EIS compared with patients without EIS, showed higher serum levels of glucose (p < 0.001), urea (p = 0.001), creatinine (p < 0.001), sodium (p = 0.025), and direct bilirubin (p = 0.015). Potassium level in EIS group was lower than in the group without EIS (p < 0.001). In patients with EIS, a higher amount of RBC (p = 0.030) and WBC (p < 0.001) was found.
Conclusion: The in-hospital database contains information about EIS by the bases subtypes of IS, patient demography, cardiovascular risk factors, comorbid pathology, clinical and laboratory tests, instrumental methods of examination, medications, the severity of neurological deficit, and post-stroke outcome.
Objective To address, in a practical way, the acute treatment of ischemic cerebrovascular accident CVA based on the scientific recommendations latest. Methods A bibliographic search was performed in the PubMed, Scopus, Scielo and Uptodate database from January 2012 to April 2018, using the descriptors stroke , early management , therapeutic , intravenous thrombolysis , combined treatment , mechanical thrombectomy and its combinations. The selection of the articles was made by listing those of greater relevance according to the proposed theme, both in the foreign and Brazilian literature, in a non systematic way. Results Intravenous thrombolysis with recombinant tissue plasminogen activator rtPA within 4.5 hours of onset of symptoms is considered the therapy of choice in eligible patients. According to the new guidelines, mechanical thrombectomy can be performed within 24h and, for prevention of subsequent ischemic events, revascularization between 48h and seven days of the index event in candidate patients is reasonable. Conclusions As an essential cause of death and disability in the world, acute ischemic stroke treatment has advanced rapidly in recent years, improving therapeutic methods and their combinations. In clinical practice, recognizing, stratifying and listing, quickly and effectively, the best therapy for stroke patients is paramount. Renato Serquiz E Pinheiro | Yanny Cinara T Ernesto | Irami Araújo-Neto | Fausto Pierdoná Guzen | Amália Cinthia Meneses Do Rêgo | Irami Araújo-Filho ""Ischemic Brain Vascular Accident: Acute Phase Management"" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-3 , April 2019, URL: https://www.ijtsrd.com/papers/ijtsrd23499.pdf
Paper URL: https://www.ijtsrd.com/biological-science/neurobiology/23499/ischemic-brain-vascular-accident-acute-phase-management/renato-serquiz-e-pinheiro
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
1. Guideline
European Stroke Organisation guidelines
for the management of post-stroke
seizures and epilepsy
Martin Holtkamp1
, Ettore Beghi2
, Felix Benninger3
,
Reetta Ka¨lvia¨inen4
, Rodrigo Rocamora5
and
Hanne Christensen6
; For the European Stroke Organisation
Abstract
Background: Following stroke, acute symptomatic seizures (manifestation within seven days) and epilepsy, i.e. occur-
rence of at least one unprovoked seizure (manifestation after more than seven days), are reported in 3–6% and up to
12% of patients, respectively. Incidence of acute symptomatic seizures is higher in intracranial haemorrhage (10–16%)
than in ischaemic stroke (2–4%). Acute symptomatic seizures and unprovoked seizure may be associated with unfavour-
able functional outcome and increased mortality. In view of the clinical relevance, the European Stroke Organisation has
issued evidence-based guidelines on the management of post-stroke seizures and epilepsy.
Method: A writing committee of six clinicians and researchers from five European countries and Israel identified seven
questions relating to prevention of (further) post-stroke seizures and epilepsy and to amelioration of functional outcome
and prevention of mortality. Recommendations are based on findings in randomised controlled trials and observational
studies using the grading of recommendations assessment, development and evaluation approach.
Results: In the absence of adequately powered randomised controlled trials, evidence for all recommendations is very
low. Based on findings in observational studies, some weak recommendations have been made. In most instances, we
suggest not to administer antiepileptic drugs. Due to high incidence of seizure recurrence after one post-stroke unpro-
voked seizure, secondary antiepileptic drugs prophylaxis needs to be considered.
Conclusion: Due to very low evidence, these guidelines only give some weak recommendations on prevention of
occurrence and recurrence of post-stroke acute symptomatic seizures and unprovoked seizure. Adequately powered
randomised controlled trials are required to assess interventions for post-stroke seizure management.
Keywords
Acute symptomatic seizure, antiepileptic drugs, cerebral infarction, intracerebral/subarachnoid haemorrhage, primary/
secondary prophylaxis, unprovoked seizure
Date received: 19 February 2017; accepted: 21 March 2017
Introduction
The relationship between stroke and epileptic seizures
or epilepsy is bidirectional. For 1 in 10 adult patients,
new-onset epilepsy can be attributed to stroke, and this
aetiology is seen in almost every fourth epilepsy patient
aged 65 years and above.1
Interestingly, middle-aged
and elderly patients with newly diagnosed epilepsy
have a two- to three-fold increased risk to suffer from
subsequent stroke within the next couple of years.2,3
The hypothesis behind this finding is that epilepsy in
those patients may be caused by subtle microangio-
pathic alterations predisposing to later overt
1
Epilepsy-Center Berlin-Brandenburg, Department of Neurology, Charite´
– Universita¨tsmedizin Berlin, Germany
2
IRCCS-Istituto di Ricerche Farmacologiche ‘‘Mario Negri’’,
Dipartimento di Neuroscienze, Milano, Italy
3
Rabin Medical Center, Department of Neurology, Faculty of Medicine,
Tel Aviv University, Beilinson Hospital, Tel Aviv, Israel
4
Kuopio Epilepsy Center/NeuroCenter, Kuopio University Hospital, and
Faculty of Health Sciences, School of Medicine, Institute of Clinical
Medicine, University of Eastern Finland, Kuopio, Finland
5
Epilepsy Unit, Department of Neurology, Hospital Universitario del Mar,
Barcelona, Spain
6
Department of Neurology, Bispebjerg Hospital and University of
Copenhagen, Copenhagen, Denmark
Corresponding author:
Martin Holtkamp, Epilepsy-Center Berlin-Brandenburg, Department of
Neurology, Charite´ – Universita¨tsmedizin Berlin, Germany.
Email: martin.holtkamp@charite.de
European Stroke Journal
2017, Vol. 2(2) 103–115
! European Stroke Organisation
2017
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DOI: 10.1177/2396987317705536
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2. cerebrovascular events, thus seizures may be an early
biomarker for subsequent stroke.
From the perspective of stroke, inherent neuro-
logical deficits may be accompanied by a plethora of
complications including epileptic seizures and epilepsy.
Due to their considerable social consequences such as
driving and working limitations, prevention and man-
agement of epileptic seizures are of utmost importance
in patients with stroke. Conceptually, seizures manifest-
ing as a consequence of brain injuries such as stroke are
dichotomised into acute symptomatic (ASS) and
unprovoked seizures (US) depending on the time
point of occurrence. The International League
Against Epilepsy (ILAE) defines ASS if they occur
within seven days of stroke,4
while seizures are unpro-
voked if they manifest after more than one week
(Box 1).5
Previously, ASS have been referred to as
‘early seizures’ and US as ‘late seizures’, but in the
last years, these terms have been abandoned. If at
least one US occurs in a patient with an enduring pre-
disposition of the brain to generate further seizures and
if the probability of further seizures is similar to the
general recurrence risk after two unprovoked seizures
(at least 60%), this patient has epilepsy, following the
recent ILAE redefinition of the condition.6
Thus, one
unprovoked seizure due to stroke is post-stroke
epilepsy.
Multiple epidemiological studies have consistently
reported that incidence of ASS in all stroke patients
lies between 3 and 6%.8–13
Incidence rates are higher
in patients with intracranial, i.e. intracerebral or sub-
arachnoid, haemorrhage rising to 10 to 16%.10,11
Independent risk factors identified by multivariate ana-
lyses include cortical involvement, total anterior circu-
lation infarct, severe stroke, and haemorrhagic
transformation of ischaemic stroke.8–13
Continuous
EEG monitoring in the intensive care setting has
demonstrated that a substantial portion of stroke
patients has electrographic seizures without a clinical
correlate. In 102 patients with intracerebral haemor-
rhage, 18% had unequivocal seizure patterns in the
EEG, while only one patient exhibited behavioural seiz-
ures.14
As by now the clinical significance of pure elec-
trophysiological seizures is undetermined, these
paroxysmal EEG phenomena are not considered in
the current guideline. For recommendations on the
use of continuous EEG in critically ill stroke patients,
we refer to the consensus statement from the
Neurointensive Care Section of the European Society
of Intensive Care Medicine.15
Unprovoked seizures, i.e. post-stroke epilepsy, have
been reported in 10 to 12% of patients with a follow-up
of 5 to 10 years16,17
when the new practical definition of
epilepsy is applied.6
Interestingly, the risk is similar
considering ischaemic infarction and different forms
of intracranial bleeding such as intracerebral and
subarachnoid haemorrhage. Independent risk factors
comprise cortical involvement and stroke size and
severity.16–20
In patients with subarachnoid haemor-
rhage, independent predictors include accompanying
intracerebral haemorrhage of more than 15 cm3
volume, Hunt & Hess grade III-V, and ASS.21
Some epidemiological studies have addressed the
question if ASS or US determines unfavourable func-
tional outcome or increased mortality, but findings are
contradictory.9,10,17,19,22–28
So far, no clear consensus exists on indications for
primary or secondary prophylaxis with antiepileptic
drugs (AED) in regard of post-stroke ASS and
US.29,30
Therefore, the European Stroke Organisation
(ESO) decided to issue guidelines incorporating recom-
mendations on how to prevent or manage post-stroke
seizures and epilepsy. These recommendations are
based on findings in randomised controlled trials
(RCTs) and observational studies. They were agreed
on in consensus by the involved authors using the
Box 1. Definitions of terms used in the current guidelines.
Term Definition.
Acute symptomatic seizure (ASS) Epileptic seizure occurring in close temporal relationship with a systemic disturbance (e.g.
severe metabolic derangement) or an acquired brain lesion (e.g. stroke); in stroke, a
seizure is regarded to be acute symptomatic if occurrence is within seven days.4
Unprovoked seizure (US) Epileptic seizure occurring beyond close temporal relation to any acute systemic dis-
turbances or acutely acquired brain lesion; may occur due to a remote lesion, after
more than seven days.7
Primary AED prophylaxis Administration of an AED in patients without previous seizures in order to prevent
seizure occurrence.
Secondary AED prophylaxis Administration of an AED in patients with at least one seizure in order to prevent seizure
recurrence.
AED: antiepileptic drug.
104 European Stroke Journal 2(2)
3. grading of recommendations assessment, development
and evaluation (GRADE) approach and the ESO
standard operating procedure (SOP) for guidelines
development31
and have the approval of the ESO
Executive Committee.
The aim of this Guideline document is to assist phys-
icians treating patients with ischaemic or haemorrhagic
stroke with or without additional seizures or epilepsy,
both in the acute hospital-based setting (emergency
physicians, neurologists) and on a long-term outpatient
basis (general practitioners, internists, neurologists), in
their clinical decisions with regard to primary or second-
ary prophylactic management with antiepileptic drugs.
Methods
A group of six clinical researchers with expertise in epi-
lepsy and/or stroke from five European countries and
Israel was proposed by the Guidelines Committee of
the ESO and confirmed by the ESO Executive
Committee. The leader of this group (MH) and four
other group members (EB, FB, RK, RR) have a
long-standing clinical and scientific expertise in epilep-
tology. The co-leader of this group (HC) has a long-
standing clinical and scientific expertise in stroke, she
was involved in the development of previous ESO
guidelines and of the ESO guideline SOP.31
Following
the ESO guideline SOP, selection of leaders and mem-
bers of the group were based on scientific integrity,
professionalism, self-motivation, clinical expertise,
availability, and conflicts of interest.31
Standardised
steps which were undertaken by the working group
are summarised in the following:
(1) The group discussed and decided by consensus on
specific and clinically relevant PICO (patient, inter-
vention, comparator, outcome) therapeutic ques-
tions. The entire process of creating these
guidelines was guided by the GRADE working
group’s recommendations32
and the ESO SOP.31
(2) The group identified all available publications
related to the PICO questions in a broad single
search. These were guided by the 2011 Centre for
Evidence Based Medicine’s levels of evidence.33
We
searched the Cochrane database of systematic
reviews (CDSR), the Cochrane central register of
controlled trials (CENTRAL) as well as
MEDLINE (1990 through March 2016).
Furthermore, we searched the reference lists of
review articles and clinical trials on post-stroke seiz-
ures and epilepsy for further appropriate studies
(for details, see online Appendix 2).
(3) The group selected eligible studies. Due to the
rather small number of PICO questions (n ¼ 7)
and authors (n ¼ 6), all members of the working
group independently screened the relevant articles
identified by the electronic search. As we identified
only few RCTs and no systematic reviews or meta-
analyses of RCTs, we also included observational
and epidemiological studies that may allow creating
recommendations or proposals.
(4) The group graded quality of evidence of RCTs and
strength of recommendations by use of the
GRADE approach. The final summaries of the
quality and strength of evidence and recommenda-
tions for each PICO question were discussed by the
whole group, recommendations were agreed on by
the majority of authors.32
Quality of evidence was
graded into high, moderate, low, and very low (for
definitions, see Box 2). Strength of recommendation
was assessed according to specific features and
levels of strength were dichotomised to be either
strong or weak (Box 3). Weak recommendations
are also termed suggestions. Wording of treatment
recommendations referred to published guidance.34
(5) The group generated ‘additional information’ mostly
based on observationaland epidemiological studies or
common clinical practice which were not used for cre-
ation ofthe present recommendations34,36
butfor pro-
posals on how to manage the patients.
(6) This guideline document has been discussed during a
plenary session during the ESO-Karolinska Stroke
Update Conference in November 2016. It was
approved by consensus by the members of the work-
ing group for the preparation of the ESO Guidelines
about management of post-stroke seizures and epi-
lepsy (online Appendix 1A). It was reviewed by two
Box 2. Grades of quality of evidence.31
Category Definition and symbol.
High Further research is very unlikely to change
our confidence in the estimate of the effect.
ÈÈÈÈ
Moderate Further research is likely to have an important
impact on our confidence in the estimate of
effect and may change the estimate.
ÈÈÈ
Low Further research is very likely to have an
important impact on our confidence in the
estimate of effect and is likely to change the
estimate
ÈÈ
Very low Any estimate of effect is very uncertain
È
Holtkamp et al. 105
4. external reviewers (online Appendix 1D online), who
did not carry any responsibility for its integrity. It was
submitted to and approved for publication by the
ESO Guidelines Committee (online Appendix 1B)
and the ESO Executive Committee (online
Appendix 1C).
Results
The working group formulated seven PICO questions
which refer to post-stroke seizure occurrence or recur-
rence as well as to functional outcome and mortality.
Literature search identified more than 5000 articles on
stroke and seizures or epilepsy in patients (see online
Appendix 2). Only three of those reported RCTs. These
and some larger observational studies were considered
to answer the PICO questions. Recommendations are
summarised in Box 4.
Box 3. Definitions and symbols of categories of strength of
recommendation.31,35
Category Definition and symbol
Strong for an
intervention
The desirable effects of an intervention
clearly outweigh its undesirable effects.
""
Weak for an
intervention
The desirable effects of an intervention
probably outweigh the undesirable
effects.
"?
Weak against
an
intervention
The undesirable effects of an intervention
probably outweigh the desirable effects
#?
Strong against
an
intervention
The undesirable effects of an intervention
clearly outweigh its desirable effects.
##
Box 4. Summary of recommendations and suggestions.
Recommendation on PICO question
Quality of
evidence
Strength of
recommendation
In the presence of only one underpowered RCT, there is no evidence if
immediate primary prophylaxis with an antiepileptic drug compared to no
treatment prevents occurrence of ASS in ischaemic stroke or intracranial
(intracerebral or subarachnoidal) haemorrhage. Based on low incidence
of ASS in observational studies, we make a weak recommendation against
primary AED prophylaxis
Very low (È) Weak against strong
intervention (#?)
In the absence of RCTs, we cannot make strong recommendations when
and in whom to treat ASS with immediate secondary AED prophylaxis
compared to no treatment for prevention of further ASS. Low incidence
of ASS recurrence suggests not implementing secondary prophylaxis
Very low (È) Weak against intervention
(#?).
In the absence of RCTs, we cannot make strong recommendations when to
start immediate primary prophylaxis with an AED to prevent occurrence
of post-stroke US. Low incidence of US occurrence suggests not imple-
menting secondary prophylaxis
Very low (È) Weak against intervention
(#?).
In the absence of RCTs but on the basis of observation study finding we
cannot make strong recommendations. Due to high seizure recurrence
risk, we suggest considering secondary AED prophylaxis.
Very low (È) Weak against intervention
("?)
There is insufficient evidence from RCTs to recommend temporary treat-
ment with an AED or any other pharmacological substance in order to
reduce the risk of subsequent US. But due to overall low incidence of
post-stroke US, we suggest not employing temporary AED treatment
Very low (È) Weak against intervention
(#?)
There is no consistent evidence from RCTs to support use against of AED
to improve functional outcome after stroke. We suggest not adminis-
tering AED treatment
Very low (È) Weak against intervention
(#?)
There is insufficient evidence from RCTs to recommend temporary treat-
ment with an AED to reduce mortality. We suggest not administering
AED treatment
Very low (È) Weak against intervention
(#?).
PICO: patient, intervention, comparator, outcome; RCT: randomised controlled trial; ASS: acute symptomatic seizure; AED: antiepileptic drug;
US: unprovoked seizure.
106 European Stroke Journal 2(2)
5. (1) For adults with ischaemic stroke or intracranial
haemorrhage, does immediate primary prophylaxis
with an antiepileptic drug compared to no treat-
ment prevent occurrence of acute symptomatic
seizures?
One RCT was identified which compared valproate
(n ¼ 36) to placebo (n ¼ 36) administered directly after
intracerebral haemorrhage.37
There was no significant
difference between groups regarding prevention of
ASS (defined in that study as manifestation within
first 14 days). This study was underpowered, preven-
tion of ASS was not one of the primary endpoints.
The quality of evidence was downgraded to very low
due to the fact that there is only one small RCT and
due to serious imprecision of the effect estimate
(Table 1). All other data on ASS are observational,
report the incidence of post-stroke ASS, and analyse
independent risk factors. Overall incidence for ASS
following stroke is low (3–6%). Risk is increased in
intracerebral or subarachnoid haemorrhage (10–
16%). Cortical involvement enhances the risk in
ischaemic stroke, in particular in haemorrhagic trans-
formation, and primary intracerebral haemorrhage
(up to 35%).9
Recommendation: The presence of only one under-
powered RCT does not give any reliable evidence if
immediate primary prophylaxis with an antiepileptic
drug compared to no treatment prevents occurrence
of ASS in ischaemic stroke or intracranial (intracer-
ebral or subarachnoid) haemorrhage. Observational
studies show that in most patients with stroke, the
risk to develop ASS is very low (approximately 5%).
Furthermore, the consequences of ASS probably are
rather limited. Thus, only a weak recommendation
can be made, and we suggest not generally employing
primary AED prophylaxis.
Quality of evidence: Very low (È).
Strength of recommendation: Weak against (#?).
Additional information: There are situations with a
higher risk of ASS occurrence such as primary intracer-
ebral haemorrhage with cortical involvement.
Nevertheless, even in such cases, the risk does not
exceed 35%, and AED prophylaxis is therefore gener-
ally not justified. If for some reason, primary AED
prophylaxis for ASS had been employed, treatment –
due to rather low long-term risk of US – should be
stopped after the acute phase.
(2) For adults with ischaemic stroke or intracranial
haemorrhage who have suffered at least one acute
symptomatic seizure, does immediate secondary
prophylaxis with an antiepileptic drug compared to
no treatment prevent occurrence of further acute
symptomatic seizures?
No RCTs are available on the question if – in
patients who have suffered at least one ASS – immedi-
ate secondary prophylaxis with an AED compared to
no treatment prevents occurrence of further ASS. Risk
of acute recurrence of ASS (within seven days of the
same stroke) is 10–20%.25,38
Recommendation: The absence of RCTs does not
give guidance for a recommendation on when and
whom to administer secondary AED prophylaxis com-
pared to no treatment for prevention of further ASS.
Findings from observational studies indicate that acute
seizure recurrence after one ASS is low (10–20%).
Thus, only a weak recommendation can be made, and
we suggest not generally employing secondary AED
prophylaxis.
Quality of evidence: Very low (È).
Strength of recommendation: Weak against (#?).
Additional information: Though acute seizure recur-
rence risk after one post-stroke ASS is low, AED sec-
ondary prophylaxis seems to be common in many
centres probably to reduce the risk of clinical worsen-
ing in the acute setting. The underlying concept of this
approach likely is based on pathophysiological consid-
erations such as increased neuronal excitotoxicity,
peri-infarct depolarisations, and inflammatory
response.39
These are considered to be risk factors
for acute recurrence of epileptic seizures, and therefore
clinicians may tend to administer AED. However, the
10-year-risk of an unprovoked seizure after one post-
stroke ASS is 30%.7
Being so, we encourage with-
drawing AED – if administered after one ASS –
after the acute phase.
(3) For adults with ischaemic stroke or intracranial
haemorrhage, does continuous primary prophylaxis
with an antiepileptic drug compared to no treatment
prevent occurrence of unprovoked seizures?
No RCTs are available on prevention of unpro-
voked post-stroke seizures with vs. without sustained
primary AED prophylaxis. Some observational studies
focus on the incidence of US (10–12%, increasing with
time after stroke) and risk factors for US (cortical
involvement, ASS, severe stroke). Patients with intra-
cerebral haemorrhage and cortical involvement, age
<65 years, volume >10 ml and ASS had an US risk
of 46.2%.17
Patients with subarachnoid haemorrhage
and accompanying intracerebral haemorrhage of more
than 15 cm3
volume had an US risk of 33% after five
years.21
In 80 patients with malignant middle cerebral
artery (MCA) infarction and craniectomy, US occurred
in 44.8% after a median of seven months. Independent
predictor for US was delayed surgery (> 42 h). There
was no influence of primary AED prophylaxis on seiz-
ure occurrence.40
Holtkamp et al. 107
7. Recommendation: In the absence of RCTs, there is
no reliable evidence to support the decision to start
immediate and sustained primary prophylaxis with an
AED to prevent occurrence of unprovoked post-stroke
seizures. As in most patients with ischaemic stroke or
intracranial (intracerebral or subarachnoid) haemor-
rhage, the risk to develop US is low (approximately
10%), we suggest not generally employing primary
AED prophylaxis.
Quality of evidence: Very low (È).
Strength of recommendation: Weak against (#?).
Additional information: Incidence of US in intracer-
ebral haemorrhage associated with presence of four
additional variables (cortical involvement, age 65
years, volume 10 ml and AS) is almost 50%.17
Primary long-term AED prophylaxis may be an
option in these patients, but in general, AEDs are not
prescribed to patients if the risk of unprovoked seizures
does not exceed 50%. In patients with malignant MCA
infarction and craniectomy, incidence of US is also
almost 50% but available data indicate that primary
AED prophylaxis has no effect.40
(4) For adults with ischaemic stroke or intracranial
haemorrhage who have suffered at least one unpro-
voked seizure, does continuous secondary prophylaxis
with an antiepileptic drug compared to no treatment
prevent occurrence of further unprovoked seizures?
No RCTs are available on prevention of further
unprovoked post-stroke seizures after one index US
with vs. without secondary AED prophylaxis. US
recurrence risk is reported to be higher than 70% in
10 years.7
Two RCTs compared efficacy of each two
different AED after stroke. In these underpowered
trials, seizure freedom rates after 12 months did not
differ comparing levetiracetam and carbamazepine41
and comparing lamotrigine and carbamazepine.42
Recommendation: The absence of RCTs does not
guide us to make a recommendation if – after an
index US – immediate secondary prophylaxis with an
AED should be implemented to prevent occurrence of
further unprovoked post-stroke seizures. Findings from
observational studies indicate high seizure recurrence
risk (70%) after one post-stroke US. Thus, employing
secondary AED prophylaxis after one US needs to be
considered.
Quality of evidence: Very low (È).
Strength of recommendation: Weak for (?).
Additional information: Following the current ILAE
definition of epilepsy, the condition can be diagnosed
after one US if the probability for another US is at least
60% within the next 10 years.6
Therefore, one post-
stroke US constitutes post-stroke epilepsy. Secondary
AED prophylaxis – if employed at all – may be
continued permanently, as seizure recurrence risk
after AED withdrawal in patients with lesional epilepsy
has been reported to be higher than 50%.43,44
A meta-
analysis identified seizure onset in adults as compared
to minors as another risk factor.45
In post-stroke epi-
lepsy, the potential decision to discontinue AEDs at
some time point needs to be individualised to the
accordant patient.
(5) For adults with ischaemic stroke or intracranial
haemorrhage, does immediate but temporary
pharmacological treatment prevent the later occur-
rence of unprovoked seizures?
Two small RCTs are available on possible antiepi-
leptogenic effects of temporary AED treatment post-
stroke, both are underpowered. One trial compared
four-week treatment with valproate to placebo 1:1 in
72 patients with intracerebral haemorrhage and did not
find significant differences in seizure occurrence after
one year.37
The second trial aimed to compare levetir-
acetam administered for 12 weeks post-stroke to pla-
cebo, but was stopped due to poor recruitment of 16
patients, only.46
The quality of evidence was down-
graded to very low due to serious risk of bias, incon-
sistency and indirectness, and very serious imprecision
(Table 2). The forest and the funnel plots of the
included RCTs are presented in Supplemental Figure
S1. One observational study suggested that statin treat-
ment in the acute phase of ischaemic stroke was an
independent predictor for less likely development of
later US.12
Recommendation: RCTs do not provide any suffi-
cient evidence to recommend temporary treatment
with an AED or any other pharmacological substance
to reduce the risk of subsequent US. As in most
patients with stroke, the risk to develop US is low
(approximately 10%), we suggest not generally employ-
ing temporary AED prophylaxis.
Quality of evidence: Very low (È).
Strength of recommendation: Weak against (#?).
Additional information: So far, the concept of anti-
epileptogenic treatment following stroke is rather the-
oretical and not supported by basic science or clinical
evidence, it does not play a relevant role in everyday
patient care.
(6) For adults with ischaemic stroke or intracranial haemor-
rhage, does treatment with an antiepileptic drug com-
pared to no treatment ameliorate functional outcome?
Three RCTs have assessed functional outcome with
temporary post-stroke AED treatment vs. placebo. One
trial (with 849 patients) on diazepam administered for
three days did not demonstrate increased rate of patients
Holtkamp et al. 109
9. with independence (RS 3) at three months (the primary
endpoint), considering all patients.47
More patients with
independence were only demonstrated in the subgroup
with cardioembolic infarction, but the trial was not pow-
ered for this analysis. Patients with intracerebral haemor-
rhage had significantly more often pneumonia with
diazepam compared to those in the placebo group. The
second trial (with 72 patients) demonstrated that valpro-
ate compared to placebo for 1 month after intracerebral
haemorrhage was associated with significantly lower
NIHSS at 12 months.37
The third trial compared levetir-
acetam administered for 12 weeks post-stroke to placebo,
but was stopped due to poor recruitment of 16 patients,
only.46
As the available trials use different outcome scales
and do not define cut-offs allowing for dichotomised ana-
lysis of data, risk ratios cannot be calculated. There are no
trials on the effect of continuous post-stroke AED treat-
ment vs. placebo on functional outcome. All other avail-
able studies focus on the question if ASS or US are
independent risk factors for unfavourable functional out-
come, but results are ambiguous.
Recommendation: There is no consistent evidence
from RCTs to support use of AED to improve func-
tional outcome after stroke. Thus, we suggest not
employing temporary AED treatment to prevent later
occurrence of epileptic seizures.
Quality of evidence: Very low (È).
Strength of recommendation: Weak against (#?).
Additional information: Two non-randomised studies
gave hints that phenytoin as compared to levetiracetam
is associated with worse functional outcome at three
months after subarachnoid haemorrhage (mRS 3)48
and at discharge from hospital after intracranial haem-
orrhage (Glasgow Coma Score).49
Diazepam should be
used with caution after intracerebral haemorrhage due
to increased risk of pneumonia.47
(7) For adults with ischaemic stroke or intracranial
haemorrhage, does treatment with an antiepileptic
drug compared to no treatment prevent mortality?
Two RCTs have assessed mortality in post-stroke
epilepsy after temporary AED treatment compared to
no treatment. One trial did not detect significantly
different mortality rates at one year with prior val-
proate (16.6%) compared to placebo (14%) adminis-
tered for one month post-intracerebral
haemorrhage.37
The second trial compared levetirace-
tam administered for 12 weeks post-stroke to pla-
cebo, but was stopped due to poor recruitment of
16 patients, only.46
One out of nine patients on tem-
porary levetiracetam and two out of seven patients
on placebo had died within one year. The quality
of evidence was downgraded to very low due to ser-
ious risk of bias, inconsistency and indirectness, and
very serious imprecision (Table 3). The forest and the
funnel plots of the included RCTs are presented in
Supplemental Figure S2.
Recommendation: In the two available RCTs, there is
no evidence that immediate, temporary primary
prophylaxis with an antiepileptic drug reduces mortal-
ity. Thus, we suggest not employing AED prophylaxis
to prevent death.
Quality of evidence: Very low (È).
Strength of recommendation: Weak against (#?).
Additional information: Available observational stu-
dies focused on the question if post-stroke ASS or US
are independent risk factors for increased mortality, but
results are ambiguous.13,17,28
These studies did not
incorporate any therapeutic interventions.
Discussion
The very low quality of evidence of the few RCTs
assessing interventions for post-stroke seizures and epi-
lepsy does not allow making strong recommendations.
But based on some reliable observational studies, we
were able to make some weak recommendations and
suggest on how to prevent occurrence and recurrence
of post-stroke ASS and US as additional information.
This offers at least some guidance for the treating
physicians.
The only weak recommendation for consideration of
AED treatment was made for secondary prophylaxis
after one post-stroke US (PICO4). RCTs assessing
AED treatment vs. no treatment are lacking, but obser-
vational studies have shown seizure recurrence rates
within the next 10 years to be higher than 70%.7
In a
randomised open-label but underpowered study, leve-
tiracetam and sustained-release carbamazepine were
compared in patients with post-stroke US.41
Though
the excellent efficacy of the two compounds was not
different, subjective tolerability and results of neuropsy-
chological tests were significantly better in the levetir-
acetam group. In epileptology, underlying aetiology of
focal epilepsy usually does not influence the choice of
the AED. The decision on the suitable substance has to
be individualised considering patients’ age, sex, comor-
bidities, and comedication. The question of AED with-
drawal at some time point is difficult to address, this
decision as well needs to be tailored for every single
patient.
For all other six PICO questions, we suggest not to
administer AED treatment. These comprise primary
and secondary prophylaxis to prevent ASS occurrence
or recurrence (PICO1 2), continuous primary
prophylaxis for US (PICO3), temporary treatment to
prevent or mitigate epileptogenesis (PICO5), and con-
tinuous or temporary treatment to improve functional
outcome (PICO6) or to prevent mortality (PICO7).
Holtkamp et al. 111
11. In patients with ischaemic stroke and intracranial
haemorrhage, the very low evidence from the only
RCT does not allow making any strong recommenda-
tion for or against primary AED prophylaxis for ASS
(PICO1). As incidence of ASS proves to be very low, we
suggest not administering primary prophylaxis in all
patients. In some subgroups, e.g. in those with intracer-
ebral haemorrhage with cortical involvement, one out
of three patients develops ASS.10
In these cases, clin-
icians may decide individually to temporarily adminis-
ter primary AED prophylaxis (we suggest for not
longer than the acute phase). There are no studies on
which AED should be preferred. The need for rapid
titration of the drug within one day and – where appro-
priate – for intravenous administration limits the choice
of monotherapy-licensed AED to lacosamide, levetira-
cetam, phenytoin, and valproate. However, the latter
may be suboptimal in patients with haemorrhages due
to the coagulation-inhibiting properties of valproate50
though findings are conflicting.51
No RCTs are available on secondary AED prophy-
laxis after one index ASS, but observational data indi-
cate acute recurrence rates of less than 20%.25,38
Therefore, we suggest not administering secondary
AED prophylaxis. Interestingly, administration of an
AED to prevent further seizures in the acute phase of
stroke does not seem to be uncommon in clinical prac-
tise. But as with primary post-stroke AED prophylaxis
against occurrence of ASS, there is at least no need for
long-term treatment as risk for later occurrence of US
is rather low.7
We suggest terminating secondary
prophylaxis after the acute phase.
There seems to be no general need to administer
primary AED prophylaxis to prevent US (PICO3).
Some clinical conditions bear a significantly increased
risk for US including subarachnoid haemorrhage with
accompanying intracerebral haemorrhage of more than
15 cm3
volume21
and intracerebral haemorrhage with
cortical involvement, age 65 years, volume 10 ml,
and prior ASS.17
These may allow for administering
AED on a long-term basis following a primary prophy-
lactic approach.
So far, the concept of antiepileptogenic treatment
approaches is just theoretical. No clinical trial has
ever demonstrated that temporary AED treatment
after any acquired brain injury including stroke pre-
vented or mitigated epilepsy.52
A Chinese group has
published the protocol of a randomised controlled
trial on patients with intracerebral haemorrhage
which are administered valproate of placebo for seven
days post-stroke; seizure outcome will be assessed after
one year.53
Results of this trial are pending. Animal
models of post-stroke epilepsy or other acquired brain
lesions also have never demonstrated antiepileptogenic
effects, and we need a better understanding of the
pathophysiological mechanisms underlying epilepto-
genesis in order to identify targets for antiepileptogenic
treatment approaches.54
Therefore, we suggest not
administering AEDs (PICO5).
Available data from RCTs on the question if post-
stroke AED treatment has a favourable impact on
functional outcome are controversial.37,46,47
In this con-
text, we suggest not administering AED treatment
(PICO6). Some observational studies show that ASS
and/or US are associated with unfavourable functional
outcome, but up to now, it remains open if seizures are
just a marker for poor outcome. Two non-randomised
studies suggest that phenytoin as compared to levetir-
acetam is associated with unfavourable functional out-
come but evidence is low.48,49
Due to its rather poor
tolerability profile and the narrow therapeutic window,
phenytoin nowadays generally is not a first-choice AED
in focal epilepsy.
Two RCTs have addressed the question if temporary
AED treatment prevents or reduces mortality37,47
(PICO7). In both trials, accordant findings were nega-
tive but overall quality of evidence was very low.
Therefore, we cannot make a strong recommendation,
but suggest not administering AEDs.
The strengths of this guideline include its systematic
approach to literature search and guidance by the
GRADE recommendations and the ESO SOP. The
limitations of our approach reflect the extreme paucity
of RCTs on prevention and pharmacological manage-
ment of acute symptomatic and unprovoked post-
stroke seizures. At the same time, of course, this
could be also considered as strength of this Guideline
Document given that it highlights the areas which need
further research. The working group was rather small
consisting of six neurologists, but the risk of too strong
influences by single members of the group was coun-
tered by extensive internal and external review pro-
cesses. As suggested in the ESO guideline SOP, future
updates of these Guidelines may consider physicians
with specialities beyond neurology (e.g. emergency
physicians), other occupational groups (e.g. nurses),
and representatives of patients’ associations as mem-
bers of the working group.31
In summary, current evidence for management of
post-stroke seizures and epilepsy is very low. There is
an urgent need for RCTs addressing this clinically rele-
vant complication of stroke to hopefully improve out-
come and quality of life in affected patients.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of inter-
est with respect to authorship, and/or publication of this art-
icle: MH received speaker’s honoraria and/or consultancy fees
from Cyberonics, Desitin, Eisai, GlaxoSmithKline, Janssen-
Cilag, Novartis, UCB Pharma and Viropharma. EB received
Holtkamp et al. 113
12. grants from the Italian Ministry of Health, Italian Drug
Agency, UCB Pharma, EISAI, Shire, American ALS
Association, Borgonovo, Foundation, consultancy fees from
Viropharma. RK received Speaker’s honoraria and/or consult-
ancy fees from Eisai, Fennomedical, GW Pharmaceuticals,
Orion, Sage, Sandoz and UCB Pharma. The other authors
declare that there is no conflict of interest.
Funding
This guideline development received no specific grant from
any funding agency in the public, commercial, or not-for-
profit sectors.
Ethical approval
Not applicable.
Informed consent
Not applicable.
Guarantor
MH.
Contributorship
Every step in the development and writing of these guidelines
was a joint work of all co-authors.
Acknowledgements
None.
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