Navigating pediatric post-stroke epilepsy: comparative assessment of treatment strategies

Abstract

Background

Although post-stroke epilepsy (PSE) is a prevalent complication in children, optimal management remains challenging. This study evaluated the impact of different treatment modalities and antiseizure medications (ASM) on the development and management of pediatric PSE following arterial ischemic stroke.

Methods

We conducted a retrospective cohort analysis over 20 years, examining pediatric patients who experienced seizures during the course of arterial ischemic stroke. Exclusions included neonatal stroke, hemorrhagic stroke, and sinovenous thrombosis. Cut-off point of seven days were accepted as early seizures and PSE. Treatments included acute stroke therapies such as intravenous tissue plasminogen activator, mechanical thrombectomy, anti-edema therapies, and antithrombotic treatments. Medications for seizure control were categorized as acute seizure management agents (benzodiazepines and phenytoin), which are not used for long-term post-stroke epilepsy control, and long-term antiseizure medications (levetiracetam and carbamazepine) for PSE management.

Results

Among 153 patients, 99 were male, with a median age of 23 months. PSE was diagnosed in 59.5% of the cohort. Cardiac disorders were the primary etiology (32.7%). Hyperacute treatments and anti-edema therapies showed no significant impact on PSE development. Benzodiazepines and phenytoin also did not affect PSE rates. Levetiracetam was associated with a higher PSE rate (66.7%) compared to carbamazepine (45.1%) (p = 0.010). Carbamazepine demonstrated superior seizure freedom at 6 and 24 months (p = 0.024 and p = 0.014, respectively). Seizure control was achieved in 19.8% of PSE patients through dose titration, with carbamazepine showing higher efficacy (p = 0.037). ASM discontinuation rates were higher with carbamazepine (95.7%) compared to levetiracetam (79.4%).

Conclusion

Acute stroke therapies, anti-edema, and antithrombotic treatments did not lower the PSE development. Benzodiazepines and phenytoin were not effective in preventing PSE. Carbamazepine may be more effective than levetiracetam in managing pediatric PSE, providing better seizure control and higher ASM discontinuation rates. Further research is needed to confirm these findings.