Video: Post-Stroke Epilepsy — AES 2025 Expert Insights

 So nothing that will prevent post stroke epilepsy. Here's all the things you need to worry about since your doctor is doing nothing to prevent or fix the problem!

Massive incompetence shown here!

Let's see how long you've known of the problem and HAVEN'T SOLVED IT!

We've known of this problem a long time. Provide solutions!

• 10% seizures post stroke (19 posts to April 2017)

• 5% epileptic seizures after stroke (10 posts to April 2021)

• epileptic seizures (6 posts to December 2015)

• post-stroke epilepsy (17 posts to December 2016)

Video: Post-Stroke Epilepsy — AES 2025 Expert Insights

Neurology Advisor: “Can you describe your work in the epilepsy space?”

Dr Mishra: “I am a stroke doctor, a stroke neurologist, and as you know, stroke patients—with the advancement in the way we offer care(NOT RECOVERY!) to them—are surviving much longer, which is a great thing. But they also suffer from various post-stroke complications like post-stroke fatigue, dementia, and cognitive impairment. One of the complications they suffer from is post-stroke epilepsy.

Late seizures, or post-stroke epilepsy, are associated with poor functional outcomes and increased mortality. Therefore, my interest has been in bringing together colleagues from around the world to tackle this question together. This is essentially aimed at drug development to prevent epileptogenesis after stroke in this population. By understanding the mechanism of epileptogenesis, we may even be able to translate that knowledge to epilepsy from other causes, like tumors or post-traumatic [causes]. So the mission is really to understand the mechanism and to prevent epileptogenesis and thereby late seizures.”

Neurology Advisor: “How do outcomes differ between those with post-stroke epilepsy and those without seizures after stroke?”

Dr Mishra: “As I said, there are greater odds of mortality and greater odds of poor functional outcomes in patients who suffer from post-stroke seizures. We actually published a paper in JAMA Neurology a couple of years ago that included data from several papers published previously. We pulled them together and looked at the risk for decline: worsening modified Rankin Scale, the mean/median score, and also the outcomes associated with dementia. That paper revealed that the outcomes are worse on all 3 counts.”

Neurology Advisor: “What is the prevention strategy for first seizure after stroke?”

Dr Mishra: “Unfortunately, we currently lack a drug that has been proven to be associated with anti-epileptogenesis. What that means is that we currently do not have a medication that prevents the epileptogenic pathways from getting started after the brain injury—in this context, stroke. So, what is really missing is that information.

As far as strategies are concerned, we do know that individuals with greater cardiovascular risk are at greater risk of having seizures. Therefore, the strategies include tight control of cardiovascular risk. For instance, there are data—secondary data, secondary analyses of existing datasets—suggesting that the use of statins, for example, is associated with reduced seizure risk. Statins are [3-hydroxy-3-methylglutaryl-coenzyme A] reductase inhibitors; they reduce [low-density lipoprotein] and also have pleiotropic effects, such as stabilizing the blood–brain barrier. There are also some data—for instance, a paper on the use of losartan—showing that it stabilizes the blood–brain barrier and has been proposed to reduce the risk for epileptogenesis.

There are a few trials ongoing or recently finished. One is on eslicarbazepine, for example, which is an agent that may have anti-epileptogenic effects. The study is not yet published, so I don’t know the results. Similarly, there is another study from Monash University, led by Patrick Kwan and John-Paul Nicolo, called PEPSTEP, which is about perampanel as an anti-epileptogenic agent. Once we have these data, we will know if there is a signal of benefit in reducing the risk for late seizures in this population.”

Neurology Advisor: “What is the recommended approach for secondary prophylaxis?”

Dr Mishra: “For secondary prophylaxis, we currently lack a strongly worded guideline on which drugs are optimal for secondary prevention. By that, I mean that the patient has already had a seizure, and we want to reduce the risk for recurrent seizures. There are some papers, including 1 that my group published, suggesting that lamotrigine may be a reasonable agent. My colleague Johan Zelano from the University of Gothenburg also mentioned work from his group where lamotrigine appears to have a better profile for secondary seizure prevention.”

Neurology Advisor: “Do you have any takeaways for clinicians treating patients with post-stroke epilepsy?”

Dr Mishra: “We know there is a lack of strong, high-quality data to recommend 1 agent over another. But there are certain patient populations at higher risk for late seizures—for example, those with early seizures or acute symptomatic seizures. When we are confronted with patients with those features, or others known to be associated with late seizures, we should be more vigilant about their late-seizure risk and offer prophylactic treatment in a more personalized manner.

We also lack data on how long to offer antiseizure medications and which ones. But I think that is the approach. Some institutions have what we call a ‘PASS clinic’—Post-Acute Symptomatic Seizures. With this kind of methodical approach, you can follow these patients over time and manage their post-stroke seizure risk. This also helps generate data so we can move the field forward: how long to treat, which agents to use, which features are linked to greater seizure recurrence risk, and how to target that population more specifically.”