National Institutes of Health Stroke Scale (NIHSS) on admission predicts acute symptomatic seizure risk in ischemic stroke: a population-based study involving 135,117 cases

Johann Philipp Zöllner, Björn Misselwitz, Manfred Kaps, Marco Stein, Jürgen Konczalla, Christian Roth, Karsten Krakow, Helmuth Steinmetz, Felix Rosenow, Adam Strzelczyk, Johann Philipp Zöllner, Björn Misselwitz, Manfred Kaps, Marco Stein, Jürgen Konczalla, Christian Roth, Karsten Krakow, Helmuth Steinmetz, Felix Rosenow, Adam Strzelczyk

Abstract

The National Institutes of Health Stroke Scale (NIHSS) score is the most frequently used score worldwide for assessing the clinical severity of a stroke. Prior research suggested an association between acute symptomatic seizures after stroke and poorer outcome. We determined the frequency of acute seizures after ischemic stroke in a large population-based registry in a central European region between 2004 and 2016 and identified risk factors for acute seizures in univariate and multivariate analyses. Additionally, we determined the influence of seizures on morbidity and mortality in a matched case-control design. Our analysis of 135,117 cases demonstrated a seizure frequency of 1.3%. Seizure risk was 0.6% with an NIHSS score at admission <3 points and increased up to 7.0% with >31 score points. Seizure risk was significantly higher in the presence of acute non-neurological infections (odds ratio: 3.4; 95% confidence interval: 2.8-4.1). A lower premorbid functional level also significantly increased seizure risk (OR: 1.7; 95%CI: 1.4-2.0). Mortality in patients with acute symptomatic seizures was almost doubled when compared to controls matched for age, gender, and stroke severity. Acute symptomatic seizures increase morbidity and mortality in ischemic stroke. Their odds increase with a higher NIHSS score at admission.

Conflict of interest statement

J.P.Z. reports a speaker’s honorarium from Eisai. F.R. reports personal fees from Eisai, GW Pharmaceuticals, and Desitin Arzneimittel; personal fees and others from Novartis; personal fees from Medtronic; personal fees from Cerbomed; personal fees from Shire; and grants from the European Union, the German Minister for Education and Research (BMBF), the LOEWE Programm of the state of Hessen, the Deutsche Forschungsgemeinschaft (DFG), and the Detlev-Wrobel-Fonds for Epilepsy Research. A.S. reports personal fees and/or grants from Arvelle Therapeutics, Desitin Arzneimittel, Eisai, GW Pharmaceuticals, LivaNova, Marinus Pharmaceuticals, Medtronic, Sage Therapeutics, UCB Pharma, and Zogenix. None of the other authors reports conflicts of interest.

Figures

Figure 1
Figure 1
The bottom number shows the count of patients with acute symptomatic seizures in this NIHSS range (x-axis), while the upper number shows the count of patients without seizures. NIHSS = National Institutes of Health Stroke Scale.
Figure 2
Figure 2
Risk factors are sorted by ascending ORs. Red diamonds indicate ORs; vertical black bars indicate 95% confidence intervals. mRS = modified Rankin Scale, NIHSS = National Institutes of Health Stroke Scale, OAC = oral anticoagulation.
Figure 3
Figure 3
The modified Rankin Scale (mRS) score at discharge demonstrates a shift toward worse outcomes for patients with acute symptomatic seizures as compared with those without.

References

    1. Camilo O, Goldstein LB. Seizures and epilepsy after ischemic stroke. Stroke. 2004;35:1769–1775. doi: 10.1161/01.STR.0000130989.17100.96.
    1. Menon B, Shorvon SD. Ischaemic stroke in adults and epilepsy. Epilepsy Res. 2009;87:1–11. doi: 10.1016/j.eplepsyres.2009.08.007.
    1. Forsgren L, Bucht G, Eriksson S, Bergmark L. Incidence and clinical characterization of unprovoked seizures in adults: a prospective population-based study. Epilepsia. 1996;37:224–229. doi: 10.1111/j.1528-1157.1996.tb00017.x.
    1. Beghi E, et al. Recommendation for a definition of acute symptomatic seizure. Epilepsia. 2010;51:671–675. doi: 10.1111/j.1528-1167.2009.02285.x.
    1. Kilpatrick CJ, et al. Epileptic Seizures in Acute Stroke. Arch. Neurol. 1990;47:157–160. doi: 10.1001/archneur.1990.00530020053014.
    1. Bladin CF. Seizures After Stroke. Arch. Neurol. 2000;57:1617. doi: 10.1001/archneur.57.11.1617.
    1. Lamy C, et al. Early and late seizures after cryptogenic ischemic stroke in young adults. Neurol. 2003;60:400–404. doi: 10.1212/wnl.60.3.400.
    1. Szaflarski JP, et al. Incidence of seizures in the acute phase of stroke: a population-based study. Epilepsia. 2008;49:974–981. doi: 10.1111/j.1528-1167.2007.01513.x.
    1. Jungehulsing GJ, Heuschmann PU, Holtkamp M, Schwab S, Kolominsky-Rabas PL. Incidence and predictors of post-stroke epilepsy. Acta. Neurol. Scand. 2013;127:427–430. doi: 10.1111/ane.12070.
    1. So EL, Annegers JF, Hauser WA, O’Brien PC, Whisnant JP. Population-based study of seizure disorders after cerebral infarction. Neurol. 1996;46:350–355. doi: 10.1212/wnl.46.2.350.
    1. Burn J., Dennis M., Bamford J., Sandercock P., Wade D., Warlow C. Epileptic seizures after a first stroke: the Oxfordshire community stroke project. BMJ. 1997;315(7122):1582–1587. doi: 10.1136/bmj.315.7122.1582.
    1. Bryndziar T, et al. Seizures Following Ischemic Stroke: Frequency of Occurrence and Impact on Outcome in a Long-Term Population-Based Study. J. Stroke. Cerebrovasc. Dis. 2016;25:150–156. doi: 10.1016/j.jstrokecerebrovasdis.2015.09.008.
    1. Kilpatrick CJ, Davis SM, Hopper JL, Rossiter SC. Early seizures after acute stroke. Risk of late seizures. Arch. Neurol. 1992;49:509–511. doi: 10.1001/archneur.1992.00530290097017.
    1. Cleary P, Shorvon S, Tallis R. Late-onset seizures as a predictor of subsequent stroke. Lancet. 2004;363:1184–1186. doi: 10.1016/s0140-6736(04)15946-1.
    1. Reith J, Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS. Seizures in acute stroke: predictors and prognostic significance. The Copenhagen Stroke Study. Stroke. 1997;28:1585–1589. doi: 10.1161/01.str.28.8.1585.
    1. Krakow K, et al. Predictors of acute poststroke seizures. Cerebrovasc. Dis. 2010;30:584–589. doi: 10.1159/000319777.
    1. Alme KN, Engelsen BA, Naik M, Naess H. Identifying patients at risk of acute symptomatic seizure after ischemic stroke. Acta Neurol. Scand. 2017;136:265–271. doi: 10.1111/ane.12721.
    1. Conrad J, et al. Seizures after cerebrovascular events: risk factors and clinical features. Seizure. 2013;22:275–282. doi: 10.1016/j.seizure.2013.01.014.
    1. Galovic M, et al. Prediction of late seizures after ischaemic stroke with a novel prognostic model (the SeLECT score): a multivariable prediction model development and validation study. Lancet Neurol. 2018;17:143–152. doi: 10.1016/S1474-4422(17)30404-0.
    1. Strzelczyk A, et al. Prospective evaluation of a post-stroke epilepsy risk scale. J. Neurol. 2010;257:1322–1326. doi: 10.1007/s00415-010-5520-9.
    1. Arboix A, Comes E, Massons J, Garcia L, Oliveres M. Relevance of early seizures for in-hospital mortality in acute cerebrovascular disease. Neurol. 1996;47:1429–1435. doi: 10.1212/wnl.47.6.1429.
    1. Labovitz DL, Hauser WA, Sacco RL. Prevalence and predictors of early seizure and status epilepticus after first stroke. Neurol. 2001;57:200–206. doi: 10.1212/WNL.57.2.200.
    1. Zöllner Johann Philipp, Konczalla Jürgen, Stein Marco, Roth Christian, Krakow Karsten, Kaps Manfred, Steinmetz Helmuth, Rosenow Felix, Misselwitz Björn, Strzelczyk Adam. Acute symptomatic seizures in intracerebral and subarachnoid hemorrhage: A population study of 19,331 patients. Epilepsy Research. 2020;161:106286. doi: 10.1016/j.eplepsyres.2020.106286.
    1. Strzelczyk Adam, Ansorge Sonja, Hapfelmeier Jana, Bonthapally Vijayveer, Erder M. Haim, Rosenow Felix. Costs, length of stay, and mortality of super-refractory status epilepticus: A population-based study from Germany. Epilepsia. 2017;58(9):1533–1541. doi: 10.1111/epi.13837.
    1. Knake S, et al. Status epilepticus after stroke is associated with increased long-term case fatality. Epilepsia. 2006;47:2020–2026. doi: 10.1111/j.1528-1167.2006.00845.x.
    1. Xu Y, et al. Frequency, determinants, and effects of early seizures after thrombolysis for acute ischemic stroke: The ENCHANTED trial. Neurol. Clin. Pract. 2017;7:324–332. doi: 10.1212/CPJ.0000000000000384.
    1. Beghi E, et al. Incidence and predictors of acute symptomatic seizures after stroke. Neurol. 2011;77:1785–1793. doi: 10.1212/WNL.0b013e3182364878.
    1. Bentes C, et al. Post-stroke seizures are clinically underestimated. J. Neurol. 2017;264:1978–1985. doi: 10.1007/s00415-017-8586-9.

Source: PubMed

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