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

Table 1 Common frontline antiseizure medications in post-stroke care: Pragmatic starting regimens and cautions

Agent	Typical starting regimen	Titration/usual maintenance	Key cautions and interactions	When to favor	When to avoid
Levetiracetam	250-500 mg twice daily	Up-titrate by 500 mg every few days to 500-1500 mg twice daily	Renal dose adjustment; behavioral irritability possible	Polypharmacy, vascular comorbidity, minimal interactions needed	Severe behavioral issues; advanced renal failure without adjustment
Lamotrigine	25 mg daily, slow titration	25 mg → 50 mg daily after 2 weeks, then increase 50 mg every 1-2 weeks; usual 100-200 mg daily	Rash risk; very slow titration; interactions with enzyme inducers or inhibitors	Need for excellent tolerability and low interaction burden	Need for rapid control; history of severe rash
Lacosamide	50 mg twice daily	Increase to 100-200 mg twice daily over 1-2 weeks	PR prolongation and conduction disease; dizziness	Focal seizures in older adults; good tolerability needed	Known conduction abnormalities or significant bradyarrhythmia
Eslicarbazepine	400 mg daily	Increase to 800-1200 mg daily	Hyponatremia; dizziness; fewer interactions than carbamazepine	Alternative to carbamazepine with fewer interactions	Recurrent hyponatremia; severe renal impairment
Brivaracetam	50 mg twice daily	50-100 mg twice daily	Similar to levetiracetam, with fewer behavioral effects; hepatic metabolism	Prior behavioral issues with levetiracetam	Significant hepatic dysfunction
Topiramate	25 mg nightly	Increase by 25-50 mg weekly to 50-100 mg twice daily	Cognitive slowing, weight loss, and kidney stones	Obesity or migraine comorbidity	Cognitive vulnerability after stroke
Carbamazepine	100-200 mg twice daily	200-400 mg twice daily	Enzyme inducer with many interactions; hyponatremia	Limited scenarios with few interactions	Anticoagulants, statins, multiple antihypertensives; older adults
Phenytoin	100 mg three times daily or load per protocol	Level-guided	Narrow therapeutic window; arrhythmia with IV; many interactions	Rescue when IV control is needed and alternatives are unsuitable	Long-term use in older adults: Polypharmacy
Valproate	250-500 mg twice daily	500-1000 mg twice daily; level-guided	Weight gain, tremor, thrombocytopenia; interactions	Limited scenarios where alternatives are unsuitable	Older adults, polypharmacy, stroke with thrombocytopenia risk

Dosing ranges were compiled from Food and Drug Administration or manufacturer labels and standard monographs for adult focal-onset seizures; adjust to renal and hepatic function, co-medications, and local formulary. PR: P-R interval.