After stroke can come seizures. 

Risk of poststroke epilepsy can be underappreciated. 

As if a stroke weren't enough to overcome, patients who survive strokes are more likely to have seizures. The risk of seizure after ischemic stroke is at least 5%, according to recent research, while hemorrhagic strokes entail even greater risk of one or more subsequent seizures. 

Yet seizures and epilepsy after stroke are generally under-recognized by physicians, according to experts. The seizures may be missed because they may not look like typical seizures and can resemble stroke symptoms or because stroke patients have difficulty communicating about their symptoms.

However, the experts also say that there are signs, symptoms, and risk factors that physicians can use to predict the possibility of developing epilepsy after stroke.

Poststroke seizures have heterogeneous presentations, depending on what part of the brain is affected, according to Kara Sands, MD, a neurologist at Mayo Clinic in Phoenix. Consequently, they don't necessarily look like the generalized tonic-clonic seizure that most people envision when they hear the word “seizure.”

“One patient's seizure may present with limb posturing or abnormal movements, while another's might do so as clumsiness or a fall,” she said.

In addition, seizures are considered stroke mimics, explained Dr. Sands. As a result, even the most trained and experienced physician will sometimes have a tough time differentiating between the two, she noted.

When the clinician examines a patient can make a difference, said Dr. Sands. The diagnosis of seizure is much simpler if a physician enters a patient's room as he is rhythmically jerking in the midst of an active seizure event, as opposed to when he is sleeping soundly after the event has occurred, she explained.

Another challenge is that following a stroke, some patients are unable to verbalize their symptoms, which family members might fail to recognize as well, according to Archie Ong, MD, a neurologist at NorthShore University HealthSystem in Evanston, Ill.

These factors combine to make the seizures easy to overlook. “If a seizure is a convulsion, that, of course, would be obvious. But subtle seizures can occur and if the patient is unable to report them, they could go unnoticed,” said Roy Sucholeiki, MD, a neurologist at Northwestern Medicine Central DuPage Hospital in Winfield.