Association of the Timing and Type of Acute Symptomatic Seizures With Poststroke Epilepsy and Mortality

Abstract

BACKGROUND: Acute symptomatic seizures (ASyS) increase the risk of epilepsy and mortality after a stroke. The impact of the timing and type of ASyS remains unclear. METHODS: This multicenter cohort study included data from 9 centers between 2002 and 2018, with a final analysis in February 2024. The study included 4552 adults (2005 female; median age, 73 years) with ischemic stroke and no seizure history. Seizures were classified using International League Against Epilepsy definitions. We examined ASyS occurring within 7 days after stroke. The main outcomes were all-cause mortality and epilepsy. Validation of the updated SeLECT score (SeLECT-ASyS) was performed in 3 independent cohorts (Switzerland, Argentina, and Japan) collected between 2012 and 2024, including 74 adults with ASyS. RESULTS: The 10-year risk of poststroke epilepsy ranged from 41% to 94%, and mortality from 36% to 100%, depending on ASyS type and timing. ASyS on stroke onset day had a higher epilepsy risk (adjusted hazard ratio [aHR], 2.3 [95% CI, 1.3–4.0]; P =0.003) compared with later ASyS. Status epilepticus had the highest epilepsy risk (aHR, 9.6 [95% CI, 3.5–26.7]; P <0.001), followed by focal to bilateral tonic-clonic seizures (aHR, 3.4 [95% CI, 1.9–6.3]; P <0.001). Mortality was higher in those with ASyS presenting as focal to bilateral tonic-clonic seizures on day 0 (aHR, 2.8 [95% CI, 1.4–5.6]; P =0.004) and status epilepticus (aHR, 14.2 [95% CI, 3.5–58.8]; P <0.001). The updated SeLECT-ASyS model, available as an application, outperformed a previous model in the derivation cohort (concordance statistics, 0.68 versus 0.58; P =0.02) and in the validation cohort (0.70 versus 0.50; P =0.18). CONCLUSIONS: ASyS timing and type significantly affect epilepsy and mortality risk after stroke, improving epilepsy prediction and guiding patient counseling.