Post-stroke seizures and epilepsy: Risk factors, neuropsychiatric outcomes, and a management framework

Abstract

In this editorial, we comment on the article by Wang et al published in the recent issue of the World Journal of Psychiatry. Ischemic strokes constitute a substantial proportion of emergency department presentations, and post-stroke seizures represent a clinically significant subset in which clinicians must balance timely stabilization with decisions that influence long-term neurologic and psychiatric outcomes. Recent studies show that late-onset seizure, cortical involvement, and hemorrhagic infarction are independent predictors of recurrence after a first epileptic episode in ischemic stroke, and these features also align with poorer cognition and higher anxiety and depression scores. Translating these signals into practice, this editorial proposes a risk-stratified management framework: (1) Confirm stroke subtype and systematically screen for the three red-flag predictors via history, focused examination, and review of neuroimaging/early electroencephalography when clinically indicated; (2) Address precipitants and comorbidities (electrolytes/glucose abnormalities, medication interactions, sleep deprivation, infection); (3) Avoid routine primary prophylaxis, but consider early anti-seizure medication in high-risk profiles while individualizing agent selection to cerebrovascular comorbidity and drug-drug interactions; (4) Incorporate brief cognitive and mood screening to trigger early referral and follow-up pathways; and (5) Use clear disposition/discharge bundles (safety counseling, rescue plan, and expedited neurology/epilepsy clinic appointments). By centering management on validated risk markers, clinicians can better align acute decisions with long-term seizure control and neuropsychiatric outcomes.

Keywords: Cognition disorders; Electroencephalography; Risk assessment; Seizures; Stroke

Core Tip: Post-stroke seizures require pathways that combine risk stratification, timely therapy, and neuropsychiatric care. We synthesize consistent predictors and translate them into a five-step framework usable in the emergency department, stroke unit, and early follow-up. The approach endorses the use of validated tools, targeted early electroencephalography, correction of precipitants, individualized non-enzyme-inducing antiseizure therapy when indicated, and brief screening for mood and cognition with structured referral. Standardized discharge bundles and pragmatic follow-up are emphasized. Routine primary prophylaxis is discouraged.