The incidence and impact of early post-stroke seizures for successful endovascular stroke treatment: an individual patient data level analysis of trials

Importance: Early post-stroke seizures (EPSS) are one of the early complications of large vessel occlusion (LVO) following endovascular treatment (EVT). However, the association between EPSS and functional outcomes remains poorly understood. Therefore, we aimed to investigate the incidence, risk factors, and clinical outcomes of EPSS in LVO patients after recanalization. Materials and methods: This study was an individual patient data level analysis of three randomized controlled trials conducted in China, including the RESCUE-BT, DEVT, and MARVEL trials. Acute ischemic stroke patients with LVO who underwent successful EVT within 24 h of symptom onset were enrolled. EPSS were defined as seizures occurring within 7 days of stroke onset, confirmed by clinical assessment with or without electroencephalography. The primary outcome was the poor outcome 90-day modified Rankin Scale (mRS) scores of 4–6. Secondary outcomes included 90-day mortality, 90-day functional independence (mRS scores of 0–2), and early neurological function defined as National Institutes of Health Stroke Scale (NIHSS) at 5–7 days or discharge. Results: Of the 2862 patients screened for eligibility, 2524 patients achieved recanalization and were included, with a median (IQR) age of 69 (58–76) years; 1452 (57.5%) were men. A total of 71 (2.8%) patients developed EPSS. After adjustment of confounders, independent predictors of EPSS included higher baseline NIHSS scores and worse recanalization grade the expanded thrombolysis in cerebral infarction (eTICI) 2b; P < 0.05. EPSS were significantly associated with the poor outcome adjusted odds ratio: 2.85, 95% confidence interval (CI): 1.66–4.88, P < 0.01 and worse early neurological function (β coefficient: 7.48, 95% CI: 4.80–10.17, P < 0.01). Propensity score matching and sensitivity analyses also showed consistent results. Mediation analysis suggested that the harmful effect of an unfavorable recanalization grade on the poor outcome was partly explained by its association with an increased risk of EPSS, which accounted for 1.8% (95% CI: 0.3%–8.6%) of the total effect. Conclusion: EPSS is associated with the poor outcome in acute LVO patients who achieved successful recanalization. Complete recanalization might be associated with a lower risk of EPSS, potentially contributing to better functional outcomes. These findings provide clinically relevant insights for periprocedural management in acute LVO patients.