Acute seizures and the risk of post-stroke epilepsy in children with arterial ischemic stroke

Objectives

This study aims to investigate the incidence, risk factors, and long-term outcomes of acute symptomatic seizures and post-stroke epilepsy in a cohort of children and adolescents who suffered from arterial ischemic stroke (AIS-C).

Methods

Children and adolescents (aged 29 days to 16 years) with AIS-C were prospectively enrolled in the population-based Swiss Neuropediatric Stroke Registry (SNPRS) between 2000 and 2020. Demographic data, clinical presentation, and seizure characteristics were documented. Follow-up evaluations were performed at six- and 24-months post-stroke to assess the development of epilepsy. Risk factors for acute seizures and post-stroke epilepsy were analysed using univariate regression models. Of 315 patients with AIS, 201 children were male (63.5 %), with a median age of 6.1 years (IQR: 2.1–11.4). Acute seizures were observed in 75 (23.8 %) children, being the initial symptom in 44/75 (58.7 %). Status epilepticus occurred in 12/75 (16.0 %). Acute symptomatic seizures were associated with younger age (median 1.1 years [IQR 0.4–6.0] vs 7.2 years [IQR 3.8–12.2]; p < 0.001) and cortical involvement (OR 3.3; 95 % CI 1.8–6.0; p < 0.001). At the 6-month follow-up, 12 patients (4.5 %) had developed active epilepsy and 12 patients (5.4 %) at 24 months. The presence of acute symptomatic seizures did not increase the risk for epilepsy at 6 months (OR 1.5; 95 % CI 0.5 to 5.1; p = 0.47) but was associated with a higher risk at 24 months (OR 3.2; 95 % CI 1.0 to 10.7; p = 0.047). The most common stroke aetiologies, classified using the Childhood AIS Standardized Classification and Diagnostic Evaluation (CASCADE) criteria, were cardioembolic (32.0 % in patients with acute seizures vs 18.4 % in those without) and unilateral focal cerebral arteriopathy (22.7 % vs 26.4 %). Stroke aetiology remained undetermined in 20.0 % vs 31.8 %. Drug-resistant epilepsy was reported in seven children (2.2 %) with severe comorbid conditions, such as congenital heart disease and sepsis. Children with post-stroke epilepsy experienced significantly worse neurological outcomes, as measured by the Pediatric Stroke Outcome Measure (PSOM), compared to children without post-stroke epilepsy (median PSOM score 3.0 vs. 0.5, p < 0.001).

Conclusions

Acute symptomatic seizures are a common complication of paediatric ischemic stroke and are strongly associated with younger age and cortical involvement. Although these seizures do not predict early epilepsy development at 6 months, they are a risk factor for post-stroke epilepsy at 24 months. Children with post-stroke epilepsy show poorer neurological outcomes and those with severe underlying conditions are at an increased risk of drug-resistant epilepsy. These findings highlight the need for careful monitoring and early intervention in children with high-risk profiles.