Seizure
Seizures occur in roughly 20% of all strokes, and are somewhat more frequent after hemorrhage than infarct.
Most of the time, if seizures occur, they will appear at the time of stroke onset or within 24 hours. Seizures will often cause a post-ictal depressed level of consciousness, as well as worsening of the focal signs.
Most authorities recommend withholding anticonvulsants unless the seizures are recurrent.
– Status epilepticus after acute stroke is exceedingly rare.
– For recurrent seizures or status, start with fosphenytoin 20 mg/kg IV, then after 12 hours maintenance phenytoin 200–300mg per day.
– Intubation may be necessary to protect the airway in patients who already are impaired from their stroke.
– Aspiration pneumonia is common after seizures and should be assumed to occur if the seizure is generalized or intubation is necessary.
– If delayed or recurrent seizures occur, then non-sedating anticonvulsants such as the following are recommended, in this order:
– lamotrigine: 25mg per day titrating up every 2 weeks by 50mg to 150mg per day
– gabapentin: 300mg per day titrating up every 3–4 days to 1500mg per day in divided doses
– levetiracetam: 500mg every 12 hours titrating up every 2 weeks to 2000mg per day
