Seizures in childhood ischemic stroke in Taiwan

doi:10.1016/j.braindev.2008.05.006

Brain and Development

Volume 31, Issue 4, April 2009, Pages 294-299

https://doi.org/10.1016/j.braindev.2008.05.006 Get rights and content

Abstract

In this retrospective study, we collected clinical and radiographic data on children (age range, 1 month to 18 years) with symptoms and radiographic confirmation of seizure after ischemic stroke for the period of January 1996 to July 2006. Thirty-nine out of 94 children with ischemic stroke had poststroke seizures. Thirty-three out of 39 children with poststroke seizures had new onset seizures but only data of 28 were available. Infection was the most common etiology in the early poststroke seizure group (52.4%) but not in the late poststroke seizure group (0%). Infarction involving arterial ischemic stroke of anterior circulation were the most common in both the early poststroke seizure (61.9%) and the late poststroke seizure group (57.1%). Epilepsy was the most common sequelae in both the early poststroke seizure (38.1%) and late poststroke seizure group (100%). Children who had initial focal neurological sign (100% vs. 38.1%; P = 0.007) or the focal cortical dysfunction on EEG (85.7% vs. 33.3%; P = 0.029) were prone to develop late poststroke seizures. Late poststroke seizures had a high risk of developing poststroke epilepsy (100% vs. 38.1%; P = 0.007). We conclude that seizures commonly occur in childhood ischemic stroke. Most poststroke seizures developed at an early stage. Infection was the most common etiology that caused early poststroke seizures in childhood ischemic stroke. Initial focal neurological signs and focal cortical dysfunction on EEG are risk factors for developing epilepsy. Poststroke seizures did not affect mortality, but there was a significant difference in normal outcome and epilepsy between those with or without poststroke seizures.

Introduction

Jackson was the first one to observe a relationship between seizures and cerebrovascular disease in 1864 [1]. Stroke is the most common cause of seizures in the elderly, and poststroke epilepsy is the most common neurologic sequelae of stroke. Childhood stroke is defined as a sudden onset neurological deficit due to a cerebrovascular event occurring between 30 days and 18 years of age [2]. Many studies about the incidence of seizures after stroke in adults have been reported, but there are few reports about seizures in childhood ischemic stroke. Therefore, we performed this retrospective study to determine the incidence of initial seizures and poststroke epilepsy after childhood ischemic stroke occurring in a tertiary medical center in Taiwan. In addition, we also investigated the clinical presentations, radiological findings, etiologies, interictal electroencephalogram (EEG) patterns, seizure types and outcomes of initial seizure depending on the time of seizure after ischemic stroke.

Section snippets

Patients

We searched for consecutive cohort of children (1 month to 18 years) with seizure attack after ischemic stroke in the medical records database of Chung Gung Children’s Hospital, a tertiary medical center in Taiwan, from January 1996 to July 2006. Admissions for ischemic stroke were identified using the following International Classification of Disease, 9th revision (ICD-9) codes for ischemic stroke, in any discharge coding: 433 (occlusion and stenosis of precerebral arteries), 434 (occlusion of

Patients and clinical characteristics

There were total 94 children with ischemic stroke in our 10 year medical records database. Thirty-nine children with seizure attack after ischemic stroke were noted during this study. We excluded 11 patients for the following reasons: previous seizure history before stroke (6), death within initial hospitalization (1), or insufficient data (4). Therefore, 28 children whose age of first episode varied between 40 days and 16 years were enrolled in this study. There were 15 boys and 13 girls.

Discussion

Most previous clinical studies make a distinction between early and poststroke seizures based on differences in their presumed pathophysiology. Many authors defined early poststroke seizures as those occurring within 14 days after stroke [5], [6], [7]. However, Hauser et al. and Lamy et al. defined early poststroke seizures as those occurring within 1 week after stroke [8], [9]. According to the guidelines of the ILAE [4], seizures occurring more than 1 week after clinical identified cerebral

Conclusion

Seizures commonly occur in childhood ischemic stroke. Most poststroke seizures developed at an early stage. Infection was the most common etiology that caused early poststroke seizures in childhood ischemic stroke. Children who have initial focal neurological signs or the focal cortical dysfunction on EEG are prone to develop late poststroke seizures. Late poststroke seizures had a high risk of developing epilepsy. Poststroke seizures did not affect mortality, but there was a significant

References (30)

M.J. Lanska et al.
Presentation, clinical course, and outcome of childhood stroke
Pediatr Neurol
(1991)
J.S. Yang et al.
Seizures associated with stroke in childhood
Pediatr Neurol
(1995)
S. Horner et al.
EEG, CT and neurosonographic findings in patients with postischemic seizures
J Neurol Sci
(1995)
Y.Y. Lee et al.
Risk factors and outcomes of childhood ischemic stroke in Taiwan
Brain Dev
(2008)
J.H. Jackson
Epileptiform convulsions from cerebral disease
J.K. Lynch et al.
Report of the National Institute of Neurological Disorders and Stroke workshop on perinatal and childhood stroke
Pediatrics
(2002)
Proposal for revised clinical and electroencephalographic classification of epileptic seizures. From the Commission on...
Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League...
A.R. Berger et al.
Early seizures following intracerebral hemorrhage: implications for therapy
Neurology
(1988)
E. Faught et al.
Seizures after primary intracerebral hemorrhage
Neurology
(1989)

D.R. Fish et al.

The natural history of late-onset epilepsy secondary to vascular disease

Acta Neurol Scand

(1989)

R.-L.M. Hauser WA et al.

Risk for seizures and epilepsy following cerebrovascular insults

Epilepsia

(1984)

C. Lamy et al.

Early and late seizures after cryptogenic ischemic stroke in young adults

Neurology

(2003)

J. Aicardi et al.

Acute hemiplegia in infancy and childhood

Dev Med Child Neurol

(1969)

G.E. Solomon et al.

Natural history of acute hemiplegia of childhood

Brain

(1970)

Cited by (26)

Risk Factors of Post-Stroke Epilepsy in Children; Experience from a Tertiary Center and a Brief Review of the Literature
2021, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Since patients with VES were included in the early seizure group, these nuances may be explained by the majority being in the VES group. Some researchers reported PSE at the rate of 80–100% in patients with late seizures, but the mean age was high in these studies.6,29 In our study, no case experienced seizures after seven days.
Acute seizures and post-stroke epilepsy have been reported more frequently in patients with pediatric stroke than adults. Acute seizures in the first days of a stroke may deteriorate stroke and ischemia-related neurodegeneration and contribute to the development of post-stroke epilepsy. In this study, we aimed to investigate risk factors for the development of post-stroke epilepsy in children with arterial ischemic stroke.
We recruited 86 children with arterial ischemic stroke. We analyzed variables, including age at admission, gender, complaints at presentation, focal or diffuse neurologic signs, neurologic examination findings, laboratory investigations that were conducted at admission with stroke (complete blood cell count, biochemical-infectious-metabolic-immunological investigations, vitamin B12 levels, vitamin D levels), neuroimaging results, etiologies, time of the first seizure, time of remote seizures, and development of neurologic deficit retrospectively. Seizures during the first six hours after stroke onset were defined as ‘very early seizures’. ‘Early seizures’ were referred to seizures during the first 48 h. Patients who experienced two or more seizures that occurred after the acute phase of seizures were classified as ‘epileptic.’ A binary logistic regression analysis was used to estimate risk factors.
An acute seizure was detected in 59% and post-stroke epilepsy developed in 41% of our cohort. Binary logistic regression analysis demonstrated that ‘very early seizures’ increased epilepsy risk six-fold. Epilepsy was 16 times higher in patients with ‘early seizures’. Low vitamin D levels were defined as a risk factor for post-stroke epilepsy.
Seizures in the very early period (within the first six hours) are the most significant risk factors for the development of post-stroke epilepsy Further studies regarding seizure prevention and neuroprotective therapies are needed because post-stroke epilepsy will affect long term prognosis in patients with pediatric stroke.
Modeling poststroke epilepsy and preclinical development of drugs for poststroke epilepsy
2020, Epilepsy and Behavior
Stroke is a severe clinical issue for global public health, representing the third leading cause of death and a major cause of disability in developed countries. Progresses in the pharmacological treatment of the acute stroke have given rise to a significant decrease in its mortality rate. However, as a result, there has been an increasing number of stroke survivors living with disability worldwide. Poststroke epilepsy (PSE) is a common clinical complication following stroke. Seizures can arise in close temporal association with stroke damage and/or after a variably longer interval. Overall, PSE have a good prognosis; in fact, its responding rate to antiepileptic drugs (AEDs) is higher than other types of epilepsy. However, regarding pharmacological treatment, some issues are still unresolved. To this aim, a deeper understanding of mechanisms underlying the transformation of infarcted tissue into an epileptic focus or better from a nonepileptic brain to an epileptic brain is also mandatory for PSE. However, studying epileptogenesis in patients with PSE clearly has several limitations and difficulties; therefore, modeling PSE is crucial. Until now, different experimental models have been used to study the etiopathology of cerebrovascular stroke with or without infarction, but few studies focused on poststroke epileptogenesis and PSE. In this review, we show a brief overview on the features emerging from preclinical research into experimental PSE, which could affect the discovery of biomarkers and therapy strategies for poststroke epileptogenesis.
This article is part of the Special Issue “Seizures & Stroke”
Development of epilepsy after ischaemic stroke
2016, The Lancet Neurology
Citation Excerpt :
Children have a clearly enhanced risk of post-stroke epileptogenesis (table 1).27 Although the causes and risk factors for ischaemic stroke are different in children compared with adults, the molecular and cellular environment in the immature brain at the time of stroke seems to promote PSE development.24,25,27 In a group of 20 patients with PSE, Lamy and colleagues21 reported that the first late seizure was simple partial in ten patients, complex partial in two, secondary generalised in six, undetermined in one, and status epilepticus in one, whereas Lossius and colleagues22 reported simple or complex partial seizures in three patients and secondarily generalised seizures in 12 patients.
For about 30% of patients with epilepsy the cause is unknown. Even in patients with a known risk factor for epilepsy, such as ischaemic stroke, only a subpopulation of patients develops epilepsy. Factors that contribute to the risk for epileptogenesis in a given individual generally remain unknown. Studies in the past decade on epilepsy in patients with ischaemic stroke suggest that, in addition to the primary ischaemic injury, existing difficult-to-detect microscale changes in blood vessels and white matter present as epileptogenic pathologies. Injury severity, location and type of pathological changes, genetic factors, and pre-injury and post-injury exposure to non-genetic factors (ie, the exposome) can divide patients with ischaemic stroke into different endophenotypes with a variable risk for epileptogenesis. These data provide guidance for animal modelling of post-stroke epilepsy, and for laboratory experiments to explore with increased specificity the molecular 'mechanisms, biomarkers, and treatment targets of post-stroke epilepsy in different circumstances, with the aim of modifying epileptogenesis after ischaemic stroke in individual patients without compromising recovery.
Seizures in acute childhood stroke
2012, Journal of Pediatrics
Citation Excerpt :
Our study found patients with stroke who had clinical seizures were more likely to have focal epileptiform discharges, generalized slowing, and electrographic seizures on EEG. Although focal cortical dysfunction on EEG has been associated with an increased risk of epilepsy,26 we could not identify any specific distinguishing EEG feature as an independent risk factor for subsequent epilepsy. Although several patients who had strokes, primarily patients with SCD, were found to have earlier silent infarctions on neuroimaging, their clinical course did not differ from the other patients with sickle cell or stroke.
To describe the risk of seizures in children with acute stroke and identify factors predicting their later risk of epilepsy.
Data for patients >3.5 years of age at a tertiary care children’s hospital with acute stroke were collected and reviewed.
Seventy-seven patients were identified (mean age, 8.4 years); 21% had clinical seizures. An additional 10% of patients had a clinical seizure during the acute hospitalization. Status epilepticus was common in infants and patients with cortical strokes. Non-convulsive status epilepticus was captured only in patients with prolonged electroencephalograms and always within 24 hours of monitoring. Six months after their stroke, 24% of our patients had epilepsy, all of whom experienced seizures at initial presentation with stroke.
In our series of pediatric patients with stroke, most of the clinical seizures occurred within the first 24 hours of presentation and did not vary in stroke subtype. Status epilepticus was common, especially in infants. Epilepsy had a high likelihood of developing in the next 6 months in children with seizures in the first 24 hours of stroke onset. Prolonged electroencephalogram monitoring was useful in detecting non-convulsive status epilepticus, but not in predicting the risk of epilepsy at 6 months.
Seizures as a presenting symptom of acute arterial ischemic stroke in childhood
2011, Journal of Pediatrics
Citation Excerpt :
This observation is consistent with previous reports in children21 and adults.19,24,35 Previous studies have reported that presence of seizures at presentation predicted involvement of the anterior circulation and cortical structures.9,15,17,35 Studies in adults have demonstrated that additional lesions may be present along with the most prominent subcortical lesion, and that this more widespread disease might be responsible for seizures.36,37
To define the incidence of seizures as a presenting symptom of acute arterial ischemic stroke (AIS) in children and to determine whether younger age, infarct location, or AIS etiology were risk factors for seizure at AIS presentation.
Children aged 2 months to 18 years presenting with AIS between January 2005 and December 2008 were identified from a single center prospective pediatric stroke registry. Clinical data were abstracted, and a neuroradiologist reviewed imaging studies.
Among the 60 children who met our inclusion criteria, 13 experienced seizure at stroke presentation (22%). Median age was significantly younger in children who presented with seizures than in those who did not (1.1 years vs 10 years; P = .0009). Seizures were accompanied by hemiparesis in all patients. Three of 4 children with clinically overt seizures at presentation also had nonconvulsive seizures on continuous electroencephalography monitoring.
Twenty-two percent of children with acute AIS present with seizures. Seizures were always accompanied by focal neurologic deficits. Younger age was a risk factor for seizures at presentation. Seizure at presentation was not associated with infarct location or etiology. Nonconvulsive seizures may occur during the acute period.
Incidence and risk factors of post-stroke seizures and epilepsy: systematic review and meta-analysis
2023, Journal of International Medical Research

View all citing articles on Scopus

View full text

Original articleSeizures in childhood ischemic stroke in Taiwan

Abstract

Introduction

Section snippets

Patients

Patients and clinical characteristics

Discussion

Conclusion

Pediatr Neurol

Pediatr Neurol

J Neurol Sci

Brain Dev

Epileptiform convulsions from cerebral disease

Report of the National Institute of Neurological Disorders and Stroke workshop on perinatal and childhood stroke

Pediatrics

Early seizures following intracerebral hemorrhage: implications for therapy

Neurology

Seizures after primary intracerebral hemorrhage

Neurology

The natural history of late-onset epilepsy secondary to vascular disease

Acta Neurol Scand

Risk for seizures and epilepsy following cerebrovascular insults

Epilepsia

Early and late seizures after cryptogenic ischemic stroke in young adults

Neurology

Acute hemiplegia in infancy and childhood

Dev Med Child Neurol

Natural history of acute hemiplegia of childhood

Brain

Original article
Seizures in childhood ischemic stroke in Taiwan