A stroke, a sudden interruption of blood flow to the brain, can leave behind damaged brain tissue. This damage can disrupt the brain's normal electrical activity, leading to seizures.

While not all stroke survivors will experience seizures, for those who do, anti-seizure medications (ASMs), also known as anti-epileptic drugs (AEDs), play a crucial role in managing these events and improving quality of life. In the USA, the management of post-stroke seizures and epilepsy is a significant aspect of neurological care, with specific medications and guidelines guiding treatment.

Understanding Post-Stroke Seizures and Epilepsy

Seizures after a stroke can occur at any time, but they are most common within the first few days or weeks (classified as "early seizures") or months to years later (classified as "late seizures" or post-stroke epilepsy, PSE). The risk of developing seizures is higher after a severe stroke, a hemorrhagic stroke (bleeding in the brain), or a stroke that affects the cerebral cortex, the outer layer of the brain. While a single seizure does not automatically mean a diagnosis of epilepsy, recurrent unprovoked seizures warrant a diagnosis of post-stroke epilepsy. PSE is a serious complication associated with poorer functional outcomes, cognitive decline, and an increased risk of mortality.

The goal of anti-seizure medication for stroke patients is to prevent or reduce the frequency and severity of seizures, thereby improving neurological outcomes and overall patient well-being.

Common Anti-Seizure Medications Prescribed in the USA

Neurologists in the USA consider several factors when choosing an ASM for a stroke patient, including the type of seizure, the patient's age, other medications they are taking, and potential side effects. Some of the most commonly prescribed ASMs for post-stroke seizures include:

1. Levetiracetam (Keppra, Spritam): This is often a first-line choice due to its favorable side effect profile, minimal drug interactions, and broad spectrum of activity against both focal (partial) and generalized seizures. It is generally well-tolerated, though some patients may experience behavioral side effects like irritability or aggression.


2. Lamotrigine (Lamictal): Another commonly used ASM, lamotrigine is effective for various seizure types and has fewer cognitive side effects compared to older drugs. It is often initiated at a low dose and gradually increased due to the risk of a severe skin rash (Stevens-Johnson syndrome), especially if titrated too quickly.


3. Gabapentin (Neurontin): While primarily known for nerve pain, gabapentin is also effective for focal onset seizures. It's generally well-tolerated with common side effects including dizziness and drowsiness. It is often used as an add-on therapy.


4. Phenytoin (Dilantin, Phenytek): An older, well-established ASM, phenytoin is effective for both focal and generalized seizures. However, it requires careful monitoring of blood levels due to its narrow therapeutic index and can have more significant side effects, including drug interactions, gum overgrowth, and long-term effects on bone health. Its use may be less favored as a first-line agentin stroke patients due to these concerns.


5. Valproic Acid (Depakote, Depakene): This broad-spectrum ASM is effective for various seizure types. However, it has a more extensive side effect profile, including potential liver toxicity, weight gain, and tremor, and can have significant drug interactions.


6. Carbamazepine (Tegretol, Carbatrol): Used for focal seizures, carbamazepine can also have significant drug interactions and requires monitoring of blood levels and blood cell counts.

Newer ASMs like lacosamide (Vimpat), oxcarbazepine (Trileptal), and perampanel (Fycompa) may also be used, offering alternative options with potentially different side effect profiles.

When are Anti-Seizure Medications Prescribed?

The decision to initiate ASM therapy for post-stroke seizures is individualized.

• Early Seizures: For a single early seizure (within 7 days of stroke onset), long-term ASM therapy is not always immediately started, as these seizures may be acute symptomatic events and not recur. However, if there are specific risk factors for recurrence or the seizure is prolonged (status epilepticus), treatment might be considered.


• Late Seizures/Post-Stroke Epilepsy: If a patient experiences a late seizure (more than 7 days after stroke) or has recurrent unprovoked seizures, a diagnosis of post-stroke epilepsy is made, and long-term ASM therapy is typically recommended. The goal is to achieve seizure freedom with the lowest effective dose and minimal side effects.


• Prophylactic Use: Routine prophylactic (preventive) use of ASMs after a stroke, without the occurrence of a seizure, is generally not recommended in the USA due to lack of evidence of benefit and the risk of medication side effects. Exceptions might be considered in very specific, high-risk scenarios, but this is rare.

Important Considerations for Stroke Patients on ASMs:

• Drug Interactions: Stroke patients often take multiple medications (e.g., blood thinners, blood pressure medications, cholesterol-lowering drugs). ASMs can have significant drug interactions, so careful medication management by a neurologist and pharmacist is critical.


• Side Effects: All ASMs have potential side effects, ranging from drowsiness and dizziness to more serious issues like liver problems or skin rashes. Regular monitoring and open communication with the healthcare team are essential.


• Adherence: Consistent medication adherence is crucial for seizure control. Patients and caregivers should understand the dosing schedule and the importance of not missing doses.


• Driving Restrictions: In the USA, laws regarding driving after a seizure vary by state but generally require a period of seizure freedom (e.g., 3-12 months) before driving privileges are reinstated. This is an important consideration for stroke survivors on ASMs.


• Follow-up Care: Regular follow-up with a neurologist specializing in epilepsy or stroke is vital to monitor seizure control, adjust medication dosages, manage side effects, and assess overall neurological recovery.

In summary, anti-seizure medications are a cornerstone of treatment for post-stroke seizures and epilepsy in the USA. With a range of effective options available and careful management by a multidisciplinary healthcare team, many stroke survivors can achieve good seizure control, allowing them to focus on their rehabilitation and regain independence.