Pharmacological Strategies for Preventing Post-Stroke Seizures and Epilepsy

Yuki Kawamura^1,2*Eugen Trinka^3,4,5Terence J Quinn⁶Hedley Emsley⁷Johan Zelano^10,8,9Tomotaka Tanaka¹¹Masafumi Ihara¹¹Lauren Sansing¹²David S Liebeskind¹³Nishant K. Mishra, FRCP, PhD^12,14*

• ¹Yale School of Medicine Department of Neurology, New Haven, United States
• ²University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
• ³Department of Neurology, Center for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
• ⁴Neuroscience Institute, Center for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
• ⁵Karl Landsteiner Institute for Clinical Neuroscience, Salzburg, Austria
• ⁶University of Glasgow School of Cardiovascular & Metabolic Health, Glasgow, United Kingdom
• ⁷Lancaster University Medical School, Lancaster, United Kingdom
• ⁸Institute of neuroscience and physiology, Department of clinical neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
• ⁹Wallenberg Center of Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
• ¹⁰Department of Neurology, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Gothenburg, Sweden
• ¹¹Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
• ¹²Department of Neurology, Yale School of Medicine, New Haven, United States
• ¹³Department of Neurology, University of California Los Angeles, Los Angeles, United States
• ¹⁴VA Connecticut Healthcare System West Haven VA Medical Center, West Haven, United States

Stroke is the most common cause of new-onset seizures and epilepsy in the older population, which is associated with increased morbidity and mortality. Post-stroke seizures (PSS) are traditionally divided into early and late seizures, occurring before and after 7 days post-stroke, respectively. A single late seizure is sufficient to diagnose post-stroke epilepsy. This narrative review discusses approaches to diagnosing and treating PSS, as well as the various pharmacological agents available. Although current evidence is limited, we suggest that levetiracetam and lamotrigine may be preferred agents for preventing acute seizure recurrence. Statins, GLP-1 agonists, eslicarbazepine, perampanel, and losartan have not been evaluated yet and need further study on their ability to prevent first-time seizures in stroke patients. While clinical trials of antiseizure medications can be costly, further research into biomarkers of epileptogenesis could facilitate more feasible clinical trials to enhance the evidence base for antiseizure medications in post-stroke seizures and epilepsy.