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(Stroke. 1997;28:1590-1594.)
© 1997 American Heart Association, Inc.

Articles

Predictive Factors of Early Seizures After Acute Cerebrovascular Disease

Adrià Arboix, MD; Luis García-Eroles, MD; Juan B. Massons, MD; Montserrat Oliveres, MD Emili Comes, MD

From the Acute Stroke Unit, Service of Neurology (A.A., J.B.M., M.O., E.C.) and Intensive Care Unit (L.G.-E.), Hospitals de Barcelona de L'Aliança, Barcelona, Spain.

Correspondence to Dr Adrià Arboix, Servicio de Neurología, Hospitals de Barcelona de L'Aliança, Sant Antoni M. Claret 135, E-08025 Barcelona, Spain.

	Abstract

Top Abstract Introduction Patients and Methods Results Discussion References

 
Background and Purpose Seizures within the first 48 hours of a first stroke or transient ischemic attack (TIA) are an independent prognostic factor for in-hospital mortality. The aim of this study was to determine predictive factors of early seizures in first-ever stroke patients.

Methods Data of 1220 first-ever stroke patients admitted consecutively to an acute stroke unit of a 450-bed teaching hospital between January 1986 and December 1993 were collected from a stroke registry. Demographic, anamnestic, clinical, neurological, and neuroimaging variables in the seizure and nonseizure group were compared using the t test and the ² test. The independent predictive value of each variable on the development of early seizures was assessed with a logistic regression analysis.

Results Early epileptic seizures were diagnosed in 29 patients (2.4%). Seizures were significantly more frequent in patients with hemorrhagic stroke (4.3%) than in those with ischemic stroke (2%). Patients with seizures were significantly younger and significantly more likely to have acute confusional state, cortical involvement, large stroke, and involvement of the parietal, frontal, occipital, and temporal lobes than patients without seizures. The in-hospital mortality rate was 37.9% in the seizure group and 14.4% in the nonseizure group (P<.0005). After multivariate analysis, only cortical involvement (odds ratio of 6.01) and acute agitated confusional state (odds ratio of 4.44) were independent clinical factors for developing epileptic seizures.

Conclusions Cortical involvement in the neuroimaging studies and agitated acute confusional state at the onset of stroke were independent predictive factors of early seizures in first-ever stroke patients. The efficacy of anticonvulsant drugs in the prophylactic control of seizures should be assessed in prospective, randomized, double-blind clinical trials conducted in the subgroup of patients with the highest risk of developing epileptic seizures.

Key Words: epilepsy • stroke, acute • stroke outcome

	Introduction

Top Abstract Introduction Patients and Methods Results Discussion References

 
Little is known about predictive factors of early epileptic seizures, ie, within the first 48 hours of onset of a first stroke or TIA, in acute stroke patients. In a previous study,¹ we showed that seizures at the onset of a first-ever stroke were an independent prognostic factor for in-hospital mortality. To contribute further to the knowledge of the natural history of early seizures and the predictive factors of seizures in different stroke subtypes, we evaluated the occurrence of early epileptic seizures in a series of 1220 consecutive first-ever stroke patients involved in a prospective stroke registry.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Discussion References

 
Data for all patients with first-ever stroke or TIA admitted consecutively to the Department of Neurology of L'Aliança Hospital (an acute-care, 450-bed hospital in the city of Barcelona, Spain) between January 1986 and December 1993 were collected from an unselected, population-based stroke registry, the details of which have been reported previously.^{2 3} For the purpose of the present study, patients with a previous history of severe head trauma, intracerebral hemorrhage, ischemic stroke, or brain surgery were excluded (n=280). Subtypes of stroke were classified according to the Cerebrovascular Study Group of the Spanish Society of Neurology⁴ and included ischemic stroke (lacunar stroke, cardioembolic infarction, atherothrombotic infarction, infarction of unusual cause, infarction of undetermined origin, and TIA) and hemorrhagic stroke (parenchymal hemorrhage, subarachnoid hemorrhage, and acute spontaneous subdural and epidural hematomas). Classification of a patient as having cardioembolic stroke⁵ required the presence of a medium (maximal diameter of the lesion, 1.5 to 3 cm) or large (>3 cm diameter) cerebral infarction, cerebral cortex involvement, sudden (minutes) or acute (hours) onset, stroke onset during ordinary daily activities, peak of deficit at onset, duration of focal neurological deficit >24 hours, and identification of a commonly accepted cardiac source of embolus in the absence of confirmatory clinical (ipsilateral carotid bruit) or investigative results (Doppler ultrasonography, carotid angiography, or angiographic MRI) of lesions in the ipsilateral supra-aortic trunks. Definitions of cerebrovascular risk factors were similar to those applied in previous studies.^{1 3}

All patients were admitted to the hospital within 48 hours of onset of symptoms. On admission, demographic characteristics, salient features of clinical history and neurological examination, and laboratory tests (complete hematologic screening, routine biochemical profile, serum electrolytes, and urinalysis), chest roentgenography, and 12-lead electrocardiograph were recorded. In all patients, a brain CT scan was performed within the first week of hospital admission. Patients with negative CT findings had a second CT scan or MRI. Overall, 22.1% of patients were studied by MRI. Other investigations included arterial digital subtraction angiography in 16.2% of patients, two-dimensional echocardiography in 15.5%, Doppler ultrasonography of the supra-aortic trunks in 14.5%, and lumbar puncture in 4.8%.

Lacunar syndrome was defined as a sudden or gradual onset of a focal neurological deficit lasting >24 hours of the type described in lacunar stroke, including pure motor hemiplegia, pure hemisensory stroke, sensorimotor stroke, ataxic hemiparesis, dysarthria–clumsy hand, and atypical lacunar syndromes.⁶ Patients with lacunar syndrome whose CT scan showed either no focal abnormality or appropriate small, deep, hypodense areas <1.5 mm in diameter were diagnosed as having lacunar infarct. Patients with lacunar syndrome and an abnormal CT scan that was not compatible with lacunar infarct were diagnosed as having lacunar syndrome not due to lacunar infarct.⁷ A major hemispheric syndrome was defined as neurological signs and symptoms strongly suggesting the presence of occlusion of the internal carotid artery or the main trunk of the middle cerebral artery. Typically, this was a combination of profound sensory and motor deficits, conjugate deviation of the eyes to the side of the lesion, hemianopia, and global aphasia or anosognosia for hemiplegia with or without impairment of consciousness.⁸ Acute agitated confusional state, defined on the basis of the criteria for delirium of the Diagnostic and Statistical Manual of Mental Disorders,⁹ was diagnosed from history, initial examination, and observation during the first 48 hours of hospitalization. Other frequent causes of confusion in the elderly (intoxications, dysmetabolic diseases, sepsis, and withdrawal state) were excluded. Lesions were considered small or not visualized (lacunar infarcts and TIAs) or large (all strokes <1.5 cm in diameter excluding lacunar infarcts and TIAs). The term "cortical" referred to lesions that were cortical or corticosubcortical (partial or total involvement of the supratentorial arterial territories), and the term "subcortical" referred to lesions that were exclusively subcortical.

Early epileptic seizures were defined as those starting at the beginning or within 48 hours of the cerebrovascular event in a patient without past history of seizures. The diagnosis was based on direct observation of seizures by the medical staff at the time of hospitalization or on the history of the neurologist in charge of the patient according to reliable descriptions obtained from ambulance personnel when seizures occurred during transportation or from the patient or his/her close family members when seizures occurred at home. A simple loss of consciousness or short-lasting episodes of mental confusion were deemed insufficient for a diagnosis of epileptic seizure. Limb-shaking TIA¹⁰ and decerebrate fits were excluded. Predisposing factors for seizures (alcohol abuse or metabolic imbalance) were also recorded. Seizures were classified according to the recommendations of the International League Against Epilepsy.¹¹ The study was approved by the institutional review committee.

Statistical Analysis
Univariate analysis for each variable in relation to the presence of early seizures was made with the Student's t test for continuous variables and the ² test (with Yates' correction when necessary) for categorical variables. Statistical significance was set at P<.05. Variables were subjected to multivariate analysis with a logistic regression procedure and forward stepwise selection if P<.10 after univariate testing. The independent predictive value of each variable on the development of early seizures was analyzed in a predictive model based on demographic, anamnestic, clinical, and neuroimaging variables, with a total of nine variables. Age was used as a continuous variable with a constant OR for each year. In the predictive model, the presence or absence of early seizures (coded as 0 or 1, respectively) was the dependent variable. The level of significance required to remain in the model was .15. The parameters of the model were estimated using the maximum likelihood method.¹² ORs and 95% confidence intervals were calculated from the ß-coefficients and standard errors. The hypothesis that the logistic model adequately fit the data was tested by means of the goodness of fit ² test.¹³ The SPSS-PC+¹⁴ and BMDP¹⁵ computer programs were used for statistical analyses.

	Results

Top Abstract Introduction Patients and Methods Results Discussion References

 
Of the 1220 first-ever stroke patients, early seizures were diagnosed in 29 (2.4%). Twenty patients (69%) were men. Seizures were classified as simple partial in 8 patients (27.6%), secondary generalized partial in 3 (10.3%), and generalized tonic-clonic, apparently without a focal onset, in 18 (62.1%). An EEG was obtained within the first week after stroke in 10 patients (34.5%) with seizures. All EEGs were abnormal, showing mild nonspecific changes in 3 patients, focal slowing in 6 (including 3 with irritative morphology), and paroxysmal features in 1 patient (generalized status epilepticus).

Alcohol abuse (>80 g/d) was not significantly more frequent among patients with seizures (3.4%) than among those without seizures (2.5%). Seizures were significantly more frequent in patients with hemorrhagic stroke (9 of 208) than among those with ischemic stroke (20 of 1012) (4.3% versus 2%; P<.05) (Table 1). In 5 patients with stroke of unusual cause and seizures, causes of stroke were hematologic disorders in 2 patients (polycythemia vera in 1 and acute leukemia in 1), infections in 2 (arteritis due to neurosyphilis in 1 and infectious arteritis due to pneumococcal meningitis in 1), and homocystinuria in 1.

View this table: [in this window] [in a new window]   Table 1. Comparison of Data of 1220 Patients With First-Ever Stroke or TIAs

When the two groups with (n=29) and without (n=1191) seizures were compared, patients with seizures were significantly younger and were significantly more likely to have acute confusional state, cortical involvement, large stroke, and involvement of the parietal, frontal, occipital, and temporal lobes than patients without seizures (Table 1). Lacunar syndromes were significantly more common among patients without seizures (Table 1). The overall in-hospital mortality rate was 37.9% in the seizure group and 14.4% in the nonseizure group (P<.0005). Causes of death in the 11 patients with seizures included cerebral herniation in 5, sepsis in 2, superinfection and renal failure in 1, pneumonia in 1, sudden death in 1, and unknown cause in 1. Mean length of hospital stay was 22.8±28.5 days in the seizure group and 18.6±24.9 days in the nonseizure group (P=NS).

After multivariate analysis (Table 2), only cortical involvement (OR=6.01) and acute agitated confusional state (OR=4.44) appeared to be independent clinical factors for developing early epileptic seizures (goodness of fit ²=1202.44; df=1216; P=.6035).

View this table: [in this window] [in a new window]   Table 2. Results of Multivariate Analysis

	Discussion

Top Abstract Introduction Patients and Methods Results Discussion References

 
The percentage of seizures in this study (2.4%) compared with other hospital-based stroke data banks is similar to the 2.3% reported by Mohr et al,¹⁶ higher than the 1.4% in the series of Milandre et al,¹⁷ but lower than the 4.5% reported in the study by Kilpatrick et al¹⁸ and the 5.4% reported in the study by Giroud et al.¹⁹

The prognosis of patients with acute cerebrovascular disease and early epileptic seizures is controversial. In a previous study in patients with first-ever stroke, early seizures were found to be an independent predictive factor for in-hospital mortality.¹ In the present study, vital status at discharge was also significantly affected by the occurrence of seizures. The in-hospital mortality rate was 37.9% in the seizure group versus 14.4% in the nonseizure group. A conclusion that may be derived in clinical practice refers to the indication for early antiepileptic treatment, not only in patients with status epilepticus in whom control of seizures is clearly established, but also in patients with isolated early seizures, to prevent complications related to epileptic crisis as well the increase in neurological sequelae associated with seizures.^{20 21}

The present study was conducted to assess whether or not the subgroup of stroke patients at high risk for early epileptic seizures exhibited distinctive clinical, neurological, or neuroimaging features. The study sample consisted of a hospital-referred population of patients being admitted to an acute stroke unit and is therefore potentially subject to referral bias. Other limitations include the fact that not all seizures were observed, and focal onset was probably missed. All patients underwent a standardized clinical and radiological assessment, but additional investigations, as expected, were selective.

Two predictors of early seizures in first-ever stroke patients were identified: cortical involvement in the neuroimaging studies and the presence of acute confusional state with psychomotor agitation. These results agree in part with the study of Lancman and coworkers,²² who found that cortical involvement, large lesions, and hemorrhagic stroke were risk factors for the development of early and late seizures in the univariate analysis. In the study by Berger et al,²³ performed in patients with cerebral hematomas, the appearance of seizures was also significantly associated with evidence of blood spread to cortical regions.

Acute confusional state with psychomotor agitation was the second independent predictive factor for the occurrence of early epileptic seizures. Postictal states are a well-recognized cause of acute confusional state.^{9 10} Therefore, it is possible that some patients with episodic confusion were indeed having seizures as the cause of their confusional state. Confusion, however, may occur in response to stroke and may even be the first manifestation of a cortical or subcortical cerebral infarction,²⁴ particularly in patients with large infarcts in the distribution of branches of the right middle cerebral artery with involvement of the temporoparietal cortex and frontostriatal region,²⁵ as well as in the distribution of the left posterior cerebral artery.²⁶

Confusional syndrome after stroke has been described as a reaction to various types of stress mediated by elevated plasma cortisol levels influencing neuron function.^{27 28} Hypercortisolim is present early after acute stroke, particularly in acute confusional patients.²⁹ In the study by Fassbender and colleagues,²⁸ plasma concentrations of ACTH were significantly increased in an initial phase in stroke patients with acute confusional state and significantly correlated with the volume of brain lesions and neurological and functional outcome. According to these authors,²⁸ an early and persisting activation of the hypothalamic-pituitary-adrenal axis may secondarily reinforce damage to hypoxic brain tissue. In other studies, it has been shown that basal and postdexamethasone cortisol levels were significantly higher in stroke patients than in control subjects.²⁹ In the study by Olsson et al,³⁰ 5 of 16 patients with acute ischemic stroke associated with acute confusional state showed increased cortisol levels 30 minutes after a short ACTH stimulation test and significantly higher cortisol concentrations after the dexamethasone suppression test. Serum cortisol levels were significantly correlated to the presence of acute confusional state and limb paresis. The neurotoxicity of hormones of the hypothalamic-pituitary-adrenal axis has also been observed in experimental studies,³¹ particularly at the level of the hippocampus of the temporal lobe. It is therefore plausible that the presence of acute confusional state at the onset of stroke would reflect a situation of hypercortisolism, which in turn would reinforce the extension of brain damage and thereby contribute to the triggering of early epileptic seizures.

In agreement with observations by Kilpatrick et al,¹⁸ none of the patients with lacunar infarct or lacunar syndrome in the present study had early seizures. This finding may be explained by the small size of lesions and the classic subcortical topography of this stroke subtype.³²

The prophylactic use of antiepileptic drugs in the management of patients with stroke in, for example, a similar manner as phenytoin is used for preventing posttraumatic seizures in patients with severe head trauma³³ cannot be recommended at this moment. Some authors have emphasized the efficacy of early prophylactic antiepileptic treatment in subarachnoid hemorrhage due to rupture of an intracranial aneurysm.³⁴ In these patients, early development of generalized tonic-clonic seizures would cause an important elevation of intracranial pressure, increasing the risks of rebleeding and a higher mortality rate. In a study by Hasan et al³⁴ in which multivariate analysis was used, a high cisternal blood score and rebleeding proved to be associated with epileptic seizures after the occurrence of subarachnoid hemorrhage. These variables reflect the amount of blood in the basal cisternae, and during the first few days after subarachnoid hemorrhage, cisternal blood may have an irritative effect on the cerebral cortex, leading to seizure. In the study by Pinto et al,³⁵ hemiparesis, Hunt's grade <3, the amount of subarachnoid blood, and the presence of an aneurysm were significantly more frequent in univariate analysis among patients with seizures.

In summary, cortical involvement in the neuroimaging studies and agitated acute confusional state at the onset of stroke were independent predictive factors of early seizures in first-ever stroke patients. The efficacy of anticonvulsant drugs in the prophylactic control of seizures should be assessed in prospective, randomized, double-blind clinical trials conducted in the subgroup of patients with the highest risk of developing epileptic seizures.

	Selected Abbreviations and Acronyms

 

ACTH = adrenocorticotropic hormone EEG = electroencephalogram OR = odds ratio TIA = transient ischemic attack

	Acknowledgments

 
We thank C. Targa, MD, and M. Balcells, MD, for valuable participation in the study and Marta Pulido, MD, for editing the manuscript and translating it into English.

Received March 13, 1997; revision received May 2, 1997; accepted May 13, 1997.

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