AAN 2025 | Initiating long-term anti-seizure medication after an acute symptomatic seizure: is it justified?

I have a team that we have formed about four years ago that is called the Post-Acute Symptomatic Seizure Investigation and Outcome Network. It is formed by five hospitals from Cleveland Clinic, Yale, MGH, Rhode Island, and UNC, my center. And we’re trying to collate and understand the data variables and risk factors for these patients to be placed on seizure medication, but also data variables and risk factors for these patients to be continued on seizure medication in their long-term outcome. Why is this important? It is important because, as we spoke, acute symptomatic seizures are provoked seizures, and the definition of this is that they have a lower risk for the seizures to recur. So they’re not the same as epilepsy. But we understand that it’s important for these seizures to be controlled in the acute phase, especially, so we can improve patient outcomes and decrease mortality because these complications, acute symptomatic seizures, have been associated with both. Knowing the risk factors associated with acute symptomatic seizures and for medication prescription will allow us to properly identify patients at a higher risk for what we have probably to continue with seizure medications for a little bit longer after the acute phase in order to allow patients to recover, as neurorecovery and neuroplasticity are very important for patient recovery. But now, this doesn’t mean that the patient has to be long-life or for several months on seizure medication. In the subacute state and the chronic phase of the patient’s recovery, these patients get discharged with multiple medications for hypertension, for hyperlipidemia, for diabetes, and others. And these patients seem to be older than 65 years of age. And we also know that polypharmacy is detrimental for patients because it can have side effects and can impact the patient’s recovery. So what is next for us is to investigate what is the most appropriate recommended time of treatment for acute symptomatic seizures in this patient to prevent unnecessary long-term use of anti-seizure medications in patients that are not at risk of having a recurrence of unprovoked seizure. When we talk about acute symptomatic seizure, there have been bigger studies that have followed patients up to 10 years. The 10-year incidence of having an unprovoked seizure after acute symptomatic seizure in these studies is about 20% to 25%. So you imagine that there’s about 75% to 80% of patients that don’t need long-term use of seizure medication. So what is next is for us to stratify and to create guidelines on what is the appropriate time for seizure medication management in this patient that has had an acute symptomatic seizure in order to discontinue it when they are going for rehabilitation or after hospital discharge or after rehabilitation to make sure that they are not being on the long-term unnecessary use of an extra medication called anti-seizure medication.

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