From Acute Symptomatic Seizures to Post-Stroke Epilepsy: A Narrative Review of Diagnosis and Management

Stroke is a major cause of acquired epilepsy in adults, particularly in older individuals. However, seizures after stroke should not be regarded as a single clinical entity. Acute symptomatic seizures (ASyS) occur within the first seven days after stroke and are considered provoked events, whereas remote symptomatic seizures carry a higher recurrence risk and may fulfill the practical definition of post-stroke epilepsy (PSE). This narrative review provides a clinically oriented synthesis of current evidence on definitions, epidemiology, pathophysiology, risk factors, predictive scores, EEG and biomarker-based risk stratification, seizure prevention, and antiseizure medication (ASM) management. Current evidence does not support routine primary antiseizure medication prophylaxis for all stroke patients. In contrast, documented clinical or electrographic seizures require appropriate treatment, and established PSE often requires long-term individualized therapy. Predictive tools may help guide surveillance, EEG indication, counseling, and follow-up, but should not be used as automatic triggers for prophylactic treatment. ASM choice should account for seizure type, age, comorbidities, cognitive and psychiatric vulnerability, drug interactions, and secondary vascular prevention. Future research should focus on validated biomarkers and preventive strategies capable of modifying epileptogenesis after stroke.