European Stroke Organisation guidelines for the management of post-stroke seizures and epilepsy

Background: Following stroke, acute symptomatic seizures (manifestation within seven days) and epilepsy, i.e. occurrence 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 unfavourable 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 unprovoked 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.