Seizures After Stroke
Dr. Uri Adler
A seizure is abnormal electrical activity in the brain. “The nerves in your brain communicate with each other with electrical impulses,” said physiatrist Uri Adler, medical director and director of stroke rehabilitation at Kessler Institute of Rehabilitation. “When the normal flow of electricity is interrupted, pathologic electrical surges can occur; that is a seizure.”
Neurologist Emily Gilmore, assistant professor of neurology at Yale School of Medicine, explains it this way: “Brain cells can either excite or inhibit other brain cells from sending messages. Usually, our brains balance that excitation and inhibition to stop potentially dangerous messages. Seizures occur when there’s an imbalance, where there’s more excitation than inhibition activity.”
When brains experience this abnormal activity, the body can make abnormal movements — the whole body, or a body part, shaking violently. “But because different parts of the brain control different things, there are other types of seizures,” Adler said. “So, you can have problems with vision, or bowel or bladder control, or a person can blank out after a seizure. Then there are things called subclinical seizures where it’s not even clear that what’s happening is a seizure and the only way we know that is by doing some testing to see if parts of the brain are acting abnormally.”
How does stroke cause a seizure?
Dr. Emily Gilmore
A stroke is an injury to the brain, often called a lesion. “Essentially, what happens is the stroke damages the lining of the brain or the cortex,” Gilmore said. That damage results in scar tissue that prevents the normal flow of electrical activity, causing a seizure.
Seizures can occur immediately after, or within a few days of the stroke. Sometimes stroke can result in a seizure later than that, most typically within a month. According to the American Stroke Association, the most likely time for a post-stroke seizure to happen is within the first 24 hours. It usually starts (and stays) localized to one side of the brain, but may also generalize to both sides of the brain.
“Sometimes the damaged parts of the brain repair themselves weeks, months, even years after a stroke, and you get some scar tissue in the brain,” Adler said. “Those scars aren’t normal tissue and sometimes interrupt normal electrical activity or cause abnormal flow of electrical activity.”
Another important distinction for post-stroke seizures is whether they are provoked or unprovoked. Provoked seizures, also called acute symptomatic seizures, are the result of an acute cause like a stroke or high fever or drugs. Provoked seizures are less likely to happen again and are not considered to be epilepsy (recurrent, unprovoked seizures), and thus do not necessarily warrant lifelong, antiseizure medications.
Provoked seizures usually occur at the onset of stroke when the brain injury is acquired or due to something else, like a metabolic disturbance caused by severe infection or kidney failure. Usually, provoked seizures occur within the first week of a stroke, or in a delayed fashion, but in the setting of some other illness.
Unprovoked seizures usually happen at least a week after the initial injury and aren’t associated with any of the initial disturbances from the stroke. Also called remote symptomatic seizures, unprovoked seizures are he reason for an epilepsy diagnosis and prescribing anti-seizure medication. A single unprovoked seizure linked to a previous stroke is enough to generate a diagnosis of epilepsy. Neurological testing can pinpoint the origin of the seizure.
“Survivors can have early seizures or later seizures,” Adler said. “There are people who have seizures early on who never have later seizures, and there are people who have seizures later on that never had early ones, and then there are people who have both.”
Not all areas of the brain have the same risk for seizures. “We think that seizures are generated by the cortex rather than areas below the cortex or the brainstem,” Gilmore said. “Hemorrhagic strokes or ischemic strokes that bleed a little bit because the tissue is fragile are more likely associated with seizures when the injury involves the cortex.”
Other than injury to the cortex, the size and severity of the stroke injury may be risk factors for unprovoked seizures.
Most people have heard the terms grand mal and petit mal to describe seizures. Today doctors prefer the terms focal and generalized seizures. The CDC classifies major types of seizures as follows:
1: Generalized seizures affect both sides of the brain.
- Absence seizures. sometimes called petit mal seizures, can cause rapid blinking or a few seconds of staring into space.
- Tonic-clonic seizures, also called grand mal seizures, can make a person
- Cry out
- Lose consciousness
- Fall to the ground
- Have muscle jerks or spasms
The person may feel tired after a tonic-clonic seizure.
2: Focal seizures are located in just one area of the brain. These seizures are also called partial seizures.
- Simple focal seizures affect a small part of the brain. These seizures can cause twitching or a change in sensation, such as a strange taste or smell.
- Complex focal seizures can make a person with epilepsy confused or dazed. The person will be unable to respond to questions or direction for up to a few minutes.
- Secondary generalized seizures begin in one part of the brain, but then spread to both sides of the brain. In other words, the person first has a focal seizure, followed by a generalized seizure.
Seizures may last as long as a few minutes.
“Most poststroke seizures are focal seizures that remain focal or secondarily generalize,” Gilmore said. “The person may experience abnormal sensations or movements but retain awareness. Some patients may have focal seizures that spread to the other side (i.e. generalize) during which they lose awareness with or without associated movements.”
Neither doctor thought a single seizure or epilepsy should have much impact on survivors. “These are usually transient events that the patient recovers from, is treated for, and moves on with their recovery,” Gilmore said.
“If you have only one seizure, it doesn’t affect recovery from stroke much,” Adler said. “Some people have seizures on and off, so they’ll have a seizure and then four months later have another one; that doesn’t have a tremendous effect on their neurological recovery after a stroke. Although it does impact the patient in other ways.” He added that there is a rare condition called status epilepticus where the brain has continuous seizures and can cause additional brain damage.
What more commonly affects rehab and recovery are the medications used to treat seizures. “Sometimes those can have side effects like fatigue or just slower processing of the brain or some other side effects that could indirectly slow recovery,” Adler said.
As for whether an unprovoked seizure might trigger an opportunity for more rehab, both experts doubted it, but Gilmore did not rule it out entirely. “There is a phenomenon associated with seizures called a postictal Todd’s paralysis, when a patient has a seizure and actually develops worsening weakness that affects only one hemisphere or part of the brain of which that recovery could take hours or even a couple days,” she said. “That could warrant them coming back to the hospital and getting evaluated, and perhaps might then warrant more rehabilitation if they had already completed their rehab course.”
Single, provoked seizures do not require treatment with medication. However, unprovoked seizure in a stroke survivor meets the definition of epilepsy, which does warrant anti-seizure medication, of which there are many with a wide variety of side effects. “The most common things are soft medical changes like fatigue, cognitive slowing, delayed processing, not being able to concentrate as well,” Adler said. “Different medicines each have their own side effect profile. That’s why it’s important to see a seizure specialist to decide which is the best seizure medicine.”
According to the AHA/ASA Stroke Rehabilitation Guidelines, there is no good evidence that it is helpful for survivors who haven’t experienced unprovoked seizures to be prescribed medicine to prevent them. There is some data that suggest using these drugs may be associated with poorer outcomes for survivors. Other studies indicate that some medicines dampen neuroplasticity.
“Trying to pick an anticonvulsant that has the fewest side effects or medication interactions with the patient’s current regimen — and that the patient finds tolerable and using the lowest dose necessary to achieve seizure control — sometimes, may take trial and error,” Gilmore said. “But in general, anti-seizure medications are fairly well tolerated.”
Once a survivor with epilepsy begins medication, they may be on it for the rest of their lives because there is no set time period of being seizure free where the risk falls to zero. “If somebody has diabetes, but it’s controlled by diabetes medicines, it doesn’t mean they don’t have diabetes anymore,” Adler said. “The same thing with a seizure disorder, you could be put on medications that will control your seizures. But it doesn’t mean they don’t have the seizure problem. It just means that the medicines are treating it well.”
“I would imagine that if by 10 years the patient hasn’t had a seizure, they would be unlikely to have an unprovoked seizure but certainly could still have a provoked seizure,” Gilmore said. “Since survivors may still be at risk for provoked seizures, avoiding triggers or situations that lower the seizure threshold, like dehydration or overexertion, sleep deprivation, hypoglycemia, excessive stress, excessive alcohol consumption or illicit drug use can help to minimize that risk. Many of the lifestyle choices that we recommend for recovering stroke patients, we also recommend for patients with seizures.”
For a person having an unprovoked seizure for the first time, there are no warning signs to alert them to what’s about to happen. People who experience multiple seizures may learn what precedes their specific seizures over time. “Those are called ‘prodromes,’” Adler said. “They might be a funny feeling or a particular taste or smell or an out-of-body sensation, a memory lapse or an abnormal movement in one part of the body. But those don’t occur in everybody.”
Overall, having a seizure after stroke does not portend future problems. Adler’s suggestion: “You should see a seizure specialist and get on proper medications. Having a seizure doesn’t predict good or bad stroke recovery. You are not doomed. It shouldn’t have any direct influence over how you’re going to recover from your stroke.”
When should I call an ambulance?
An ambulance is only needed if a person has a life-threatening seizure or problems after a seizure. Examples of when to call an ambulance include:
- A seizure lasts 5 minutes or longer.
- One seizure occurs right after another without the person regaining consciousness or coming to between seizures.
- Seizures occur closer together than usual for that person.
- Breathing becomes difficult or the person appears to be choking.
- The seizure occurs in water.
- Injury may have occurred.
- The person asks for medical help.
Remember, you don’t need to call an ambulance for every seizure. Most seizures end on their own within a few minutes.
Source: When should I call an ambulance?, Epilepsy.com
First Aid For Generalized Seizures
When most people think of a seizure, they think of a generalized tonic-clonic seizure, also called a grand mal seizure. In this type of seizure, the person may cry out, fall, shake or jerk, and become unaware of what’s going on around them.
Here are things you can do to help someone who is having this type of seizure:
- Ease the person to the floor.
- Turn the person gently onto one side. This will help the person breathe.
- Clear the area around the person of anything hard or sharp. This can prevent injury.
- Put something soft and flat, like a folded jacket, under his or her head.
- Remove eyeglasses.
- Loosen ties or anything around the neck that may make it hard to breathe.
- Time the seizure. Call 911 if the seizure lasts longer than 5 minutes.
Stay with the person until the seizure ends and he or she is fully awake. After it ends, help the person sit in a safe place. Once they are alert and able to communicate, tell them what happened in very simple terms. Comfort the person and speak calmly.
Source: Seizure First Aid, Centers for Disease Control and Prevention website
Patient Profile: STEVE GROSE
Survivor Steve Grose with his significant other, Marina Nelson, and their daughter, Kenda, prior to his stroke
Steve Grose, self-employed truck driver from Apache Junction, Arizona, had an ischemic stroke in October 2014 at age 59. “The doctor called it a ‘total occlusion of the left carotid at origin.’ I’ll never forget that,” said Marina Nelson, Steve’s significant other. “The neurologist told me the results of the MRI showed almost the entire left side of his brain was white, which meant damage.” The cause was chalked up to Steve’s four-packa- day smoking habit and cholesterol over 300 mg/dL. He was a cooperative patient while in the rehab hospital but refused additional outpatient therapy once he was released.
Marina’s insurance (she is a data analyst) provided for 90 outpatient therapy visits for Steve — 50 minutes of physical therapy and the same amount of speech therapy. “But he’d get so tired doing the physical part that he couldn’t pay attention to the speech therapy,” Marina said. “He finally refused to go at all.” As a result, he has expressive and receptive aphasia — “Steve speak,” Marina calls it — as well as right-side weakness and uses a motorized wheelchair.
About eight months after his stroke, on Father’s Day weekend, Steve had his first seizure. Marina described it: “He was sitting on the commode and he started to look frightened. Then his right shoulder started to shake; then the rest of him shook. He started to grit his teeth, and his whole body went rigid. He was fighting for air through clenched teeth and slid onto the floor. I called Kenda, our daughter, to bring me the phone and called 911 while I held his head in my lap. By the time the paramedics got there, he had relaxed and was breathing normally again. It lasted two or three minutes. They transported him to the hospital even though he seemed normal, and that’s where we spent Father’s Day weekend. It fit my idea of what a seizure was supposed to look like, and I didn’t know what to do with it. It reminded me a little of my father’s diabetic reactions when his sugar would drop, only this was Steve’s whole body.”
About two months later, Steve had another seizure and then another two months after that. “I didn’t call the paramedics after that first one, because he came out of them pretty quickly and it was more stressful for him to be in the hospital than home with me,” Marina said. “We got him in to see the neurologist and he put Steve on levetiracetam, and he hasn’t had any seizures in the two years since.”
We asked Marina to ask Steve how the seizure felt. “He just raises his hand; he doesn’t have the words,” she said. “But after it happened, he always had to take a nap. It just exhausted him.”
“I’m still learning how to deal with all this, and he’s still recovering at his own pace. He has a few more words now than when we started, and we’ve finally started going a few more places in the car. After the stroke, we couldn’t go anywhere without Dramamine because he got so carsick — imagine, a truck driver who gets carsick. But as he’s learned to focus more, and I’ve learned how to accommodate him, we get along pretty well. In fact, we are headed to the biker rally in Laughlin at the end of April. We won’t be on our motorcycles, but we can go look. And he has no problem getting around the casino!”
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