ISC 2026 | Diagnosis and management of post-stroke epilepsy in older adults

The first thing is to be able to diagnose post-stroke epilepsy. Once you diagnose post-stroke epilepsy, now you have to treat and choose the correct medication. For the diagnosis of post-stroke epilepsy, it’s clinical. Epilepsy is a clinical diagnosis that can be aided by an EEG. Some of the particularities of post-stroke epilepsy are that it occurs in elderly individuals for the most part. And epilepsy in elderly individuals can be subtle, or seizures can be subtle in those patients. Even a [inaudible] that goes unnoticed can be a sign of seizures in elderly individuals. They may have language impairment that is transient, which can be confused with TIAs. One thing that was also important to pay attention to is a moral phenomenon such as lip smacking or auto-automatism or mini-automatism as well. GTCs are not uncommon, and it’s uncommon for those patients to go into what we call status epilepticus, which is like recurrent seizures, lasting more than five minutes. Now, once you have established a clinical diagnosis, you may use an EEG to sort of help confirm the diagnosis. And what we found with EEG in patients with late-onset epilepsy, post-stroke epilepsy, is that the EEG abnormalities tend to be localized to the temporal lobe. And more importantly, when you look at the models that were developed to predict late-onset post-stroke epilepsy, you realize that having focal slowing has an impact on the risk of developing post-stroke epilepsy. Now, once you combine the clinical component, which is the most important one, with the EEG component, you now arrive at a diagnosis. Again, you can get to a diagnosis with that via an EEG. The EEG is just supportive. And you have to choose which drug to prescribe to those patients. And the choice of the medication will account for the safety of that drug and also for the patient’s particular comorbidities. The two drugs that really stand out in terms of safety and I’ll argue their efficacy in post-stroke epilepsy, accounting for the patient’s age, are lamotrigine and levetiracetam. There are other drugs that can be used as well. And one important thing is to try and avoid those drugs that may have an impact on cognition. So the old sodium channel blockers are among those medications. One also important thing is to really take into consideration the fact that those patients with post-stroke seizure or post-stroke epilepsy, they have cardiovascular comorbidities. And some drugs have an impact on the cardiovascular profile of patients, such as valproic acid that can cause hyperlipidemia, obesity, and there are different medications that can do the same thing. So the whole idea is to be able to really account for the patient’s comorbidities and then look at the safety profile of medication. And the two drugs I said earlier that we choose as first-line medication in this situation are lamotrigine and levetiracetam. Of course, there is one important component that is patient education, family education, driving, and also the social impact in general of post-stroke seizures or epilepsy. Not to forget that those patients often have a comorbid cognitive impairment. Epilepsy exacerbates the cognitive impairment. The cognitive impairment is also more frequent in patients with post-stroke epilepsy. What that implies is that when you see a patient with post-stroke epilepsy, it’s really important to have at least a minimal assessment of his cognition using tests like the MoCA and make necessary referrals if needed.

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