Der Nervenarzt

, Volume 80, Issue 4, pp 405–414 | Cite as

Epileptische Anfälle und Epilepsien nach „Schlaganfall“

Leitthema
First Online:

Zusammenfassung

Epilepsien nach Schlaganfällen repräsentieren ca. 20% aller Epilepsien im Erwachsenenalter und zeigen hinsichtlich der Diagnose, Behandlung und Prognose einige Besonderheiten. Häufig scheinen die Patienten selber eine Amnesie für ihre epileptischen Anfälle zu haben, die symptomarm verlaufen können. Postiktal wurden Tage andauernde Todd-Paresen und Verwirrtheitszustände beschrieben, die die Diagnose weiter erschweren können. Einzelne epileptische Anfälle wurden nach Schlaganfällen in 2–10% der Fälle beobachtet, während populationsbasierte Studien eine Epilepsierate von 3–4% angeben. Subgruppenanalysen ergaben nach ischämischen Hirninfarkten eine Häufigkeit von Epilepsien von ca. 3%, nach intrazerebralen Blutungen von 6–10% und nach Subarachnoidalblutung ca. 9%. Ein Status epilepticus entwickelte sich nach einem Schlaganfall in weniger als 1%. Risikofaktoren für eine Epilepsie nach Schlaganfällen sind neben der Ätiologie, Spätanfälle (Latenz: >2 Wochen; Rezidivrisiko: >50%) mehr als Frühanfälle (Latenz <2 Wochen; Rezidivrisiko: <50%), Infarktgröße, kortikale Beteiligung und Schwere des neurologischen Defizits. Auf der anderen Seite stellt die Erstmanifestation von epileptischen Anfällen jenseits des 60. Lebensjahres einen Risikofaktor für einen späteren Hirninfarkt mit einer Hazard Ratio von 2,89 dar.

Es existiert zurzeit keine hinreichende Evidenz für eine antikonvulsive Primärprophylaxe nach Schlaganfällen. Während zur Einstellung nach einem ersten Frühanfall sehr unterschiedliche Meinungen vertreten werden, wird mehrheitlich wegen des hohen Rezidivrisikos eine antikonvulsive Therapie nach dem ersten Spätanfall und prinzipiell nach dem zweiten epileptischen Anfall empfohlen. Bei der Auswahl des Antikonvulsivums sind mögliche pharmakokinetische Interaktionen zu beachten. Dabei können besonders die älteren Antikonvulsiva die Komedikation beeinflussen, die in der Regel nach Schlaganfällen verabreicht wird, wie z. B. Antikoagulanzien und Thrombozytenaggregationshemmer. Nur wenige Studien untersuchten gezielt spezifische Antikonvulsiva bei epileptischen Anfällen/Epilepsien nach Schlaganfällen, wobei Lamotrigin und Gabapentin sich als günstig erwiesen haben.

Schlüsselwörter

Hirninfarkt Intrazerebrale Blutung Epilepsie Antiepileptika Epileptischer Anfall 

Seizures and epilepsies after stroke

Summary

Epilepsies after stroke represent 20% of all adult-onset epilepsies and exhibit special characteristics with respect to diagnosis, treatment, and prognosis. Patients are frequently amnestic for their seizures the signs of which can be very subtle. Postictal pareses and confusional states can last for days, which further complicate diagnosis. Single seizures after stroke were reported in 2% to 10% of cases, and community-based studies found epilepsies in 3% to 4% of stroke patients. Analyses of subgroups identified epilepsy risks of 3% after ischemic infarction, 6% to 10% after intracerebral hemorrhage, and 9% after subarachnoid hemorrhage. Status epilepticus developed in less than 1% of stroke patients. Besides etiology, further risk factors for epilepsy comprise: remote seizures (latency >2 weeks, risk of recurrence >50%) more than early seizures (latency <2 weeks, risk of recurrence <50%), extent of stroke, cortical involvement, and degree of neurological deficit. The first appearance of seizures in patients older than 60 years represents a risk factor for future stroke with a hazard ratio of 2.89.

There is currently no sufficient evidence for starting AED treatment before seizures occur. The benefit is still unclear of starting AED after a single early post-stroke seizure. Most authors recommend AED treatment after the second seizure but also after a first remote seizure because of the high risk of seizure recurrence in these situations. Possible pharmacokinetic interactions should be considered when choosing AED. Especially the first-generation AED carry the potential to interact with comedication, which is usually seen in stroke patients receiving substances such warfarin and salicylates. Only very few studies investigate specific AED exclusively in stroke patients. Lamotrigine and gabapentin have been successfully tested in these patients.

Keywords

Stroke Intracerebral hemorrhage Seizure Epilepsy Antiepileptic drug 
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Notes

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

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Copyright information

© Springer Medizin Verlag 2009

Authors and Affiliations

  1. 1.Neurologische UniversitätsklinikUKGM MarburgMarburgDeutschland

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