Monthly Case

A 67-year old male patient suffers form apoplectiform left-sided hemiparesis, predominantly affecting the upper extremity and the face. In the emergency room, the diagnosis of ischemic stroke is made. The patient is admitted to the specialized stroke unit. In the first night, for the first time he suffers a generalized tonic clonic epileptic seizure with a duration of 1 min and postictal confusion for 25 – 25 min. To prevent seizure recurrence, the patient is administered the benzodiazepine clobazam 2 x 10 mg daily, in addition he is treated with 2 x 1,000 mg levetiracetam. Clobazam is withdrawn after a couple of days, levetiracetam is continued while the patient is transferred to a rehabilitation clinic 1 week later.

This patient had an acute symptomatic epileptic seizure. This is defined as seizure manifestation within 7 days of stroke. 70% of all acute symptomatic seizures caused by stroke occur – as the current case – within the first 24 h. Approximately 5% of all patients with ischemic stroke will have an acute symptomatic seizure, in patients with hemorrhages the risk is 8%.

The clinically important question is that of the risk for recurrence of further seizures. For the acute phase, i.e. within the first 7 days of stroke, available data are not reliable. The long-term risk within the next 10 years to suffer a second – then (after more than 7 days from stroke) unprovoked – seizure is 30%. That means that more than two thirds patients with one stroke-related acute symptomatic seizure will never again have an epileptic seizure. Therefore, by definition, an acute symptomatic seizure is not epilepsy as the recurrence risk is too low.

Due to this, there is no need for long-term antiepileptic drug treatment. For the current patient, we recommended to the rehabilitation clinic to withdraw levetiracetam at latest 3 months after stroke. Unfortunately, in clinical practice this does not happen in every case.

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