Early Onset Seizures in Stroke

A 43-year-old woman with medical history of hypertension, myocardial infarction, ischemic cardiomyopathy, and systolic heart failure with an ejection fraction of 20% to 25% on a recent echocardiogram developed sudden onset of left hemiparesis, left hypoesthesia, left gaze deviation, and mutism. Two hours after symptom onset her initial National Institutes of Health Stroke Scale score was 25. A computed tomography of the head was unremarkable, but a computed tomography angiogram showed a distal right middle cerebral artery occlusion. She was given intravenous tissue-type plasminogen activator, but soon after tissue-type plasminogen activator administration, the patient had a generalized tonic clonic seizure. A repeat computed tomography of the head immediately after the seizure showed no hemorrhage, and the patient received mechanical thrombectomy for a her right middle cerebral artery occlusion. She was started on levetiracetam for secondary seizure prevention. MRI showed multiple areas of diffusion restriction involving all vascular territories consistent with a cardioembolic source and her history of dilated cardiomyopathy. She was started on anticoagulation. Importantly there were both cortical and subcortical areas with diffusion positive signal. Electroencephalography showed severe diffuse encephalopathy without epileptiform discharges. She made a good recovery and her discharge National Institutes of Health Stroke Scale score was only 4. She had no more seizures and was discharged home on warfarin, statin, and levetiracetam with seizure restrictions. Two months later she had a minimal hemiparesis and returned to work. She had no further seizures. Although it was explained that the plan had only been to continue anticonvulsants for 3 months, she wanted to drive as soon as possible and elected to continue anticonvulsants indefinitely.Stroke is …