2026 Volume 43 Issue 3 Pages 274-279
Post–stroke epilepsy (PSE) is a major cause of epilepsy in older adults and poses multifaceted clinical challenges beyond seizure control, including functional decline, psychiatric comorbidity, driving issues, diagnostic uncertainty, and long–term medication safety. Recent advances in risk stratification, such as the SeLECT and CAVE scores, and refinement of predictors including cortical superficial siderosis have improved the clinical framework for identifying patients at high risk for PSE.
This review summarizes practical strategies for optimizing interventions for PSE from three perspectives : (1) risk stratification and diagnosis, (2) treatment intervention and prevention in acute symptomatic seizures (ASS) after stroke, and (3) long–term pharmacotherapy and regional care coordination. Distinguishing ASS, typically occurring within 7 days after stroke, from late unprovoked seizures is essential because this distinction directly affects diagnosis, patient counseling, driving advice, and long–term antiseizure medication (ASM) decisions. When ASS occurs, treatment is often justified to prevent neurologic deterioration and recurrent seizures ; however, routine prophylactic ASM use in all acute stroke patients is generally not recommended. Instead, intensified monitoring and early specialist involvement should be considered in high–risk cases.
In long–term management, ASM selection should be based not only on antiseizure efficacy but also on tolerability, retention, drug–drug interactions, psychiatric effects, vascular risk, and adherence, particularly in older adults with multimorbidity. Reevaluation of apparent drug–resistant cases, including possible misdiagnosis or psychogenic nonepileptic seizures, is also important. Finally, a cyclical regional care pathway linking acute hospitals, rehabilitation facilities, primary care physicians, and epilepsy/stroke specialists is crucial for sustained optimization of PSE care.
