This retrospective cohort study investigated the incidence and burden of post-stroke seizures in Saudi Arabia. The average age of participants was 65.6 ± 12.6 years, and 61.7% were male. In the included sample, around 13.5% of patients with ischemic stroke developed post-stroke seizure. In previously published studies, the rate of post-stroke seizure in patients with ischemic stroke varied largely, ranging from 2.5 to 12% (Feher et al. 2020). This discrepancy could be explained by the heterogenicity in study design, mainly by differences in the inclusion period between stroke and seizure occurrence, ranging from 24 h to 30 days. The higher seizure incidence found in this study is anticipated as the period of inclusion between stroke and seizure was longer than in previous studies (12 months). Based on the TOAST classification (Amalia 2023), in the current study, around one-half of all stroke patients had subtype 1 (large vascular occlusion). This is consistent with a previous retrospective study reporting stroke subtype 1 to be the most prevalent, accounting for 59.6% of all stroke patients (Harris et al. 2018).

History of previous stroke was present in 39.9% of the sample; 55.1% of the seizure group, and 36.8% in the non-seizure group, Table 1. This study found an independent association between previous history of stroke and post-stroke seizure, Fig. 2. These findings align with a recent systematic review and meta-analysis, emphasizing a solid link between post-stroke seizure, heightened mortality, and severe disability in individuals with a prior history of stroke (Misra et al. 2023).

Predicting the outcome following a stroke is mainly influenced by stroke severity (Koton et al. 2022). The NIHSS score is the most frequently used scoring system worldwide to assess the severity of stroke (Amalia 2023). In the univariate model, this study reported that NIHSS score at admission was significantly associated with developing post-stroke seizures, however, this association was not significant in the multivariable model. These results are consistent with other reports indicating that a higher initial NIHSS score predicts post-stroke seizures (Alsaad et al. 2022; Zollner et al. 2020). ln addition, the present study showed stroke patients who encountered seizures exhibited a notably prolonged hospital stay and a higher rate of ICU admission compared to those who did not experience seizures. Upon using the multivariable regression model, ICU admission remained significantly associated with the occurrence of post-stroke seizure, Fig. 2. This is consistent with previous findings by Alsaad et al., in which patients with post-stroke seizure had more ICU admissions and longer length of hospital stay (Alsaad et al. 2022).

Moreover, the current report evaluated the influence of the thrombolysis and thrombectomy interventions. According to a research study conducted in the United States, there was a marked increase in post-stroke seizures in patients who underwent MT (Lekoubou et al. 2023). Approximately 1 in 20 acute ischemic stroke patients who underwent MT experienced seizures. The findings are consistent with this report which suggested that patients who underwent MT were more likely to develop post-stroke seizures, Table 1. This is in part owed to the larger vessels ischemic stroke is more severe in general (Tawil et al. 2016). Contrary to the former, thrombolysis with tPA is the preferred treatment for ischemic stroke only when administered within the critical first few hours after the onset of symptoms (Knecht et al. 2017). There was no statistically significant association between tPA therapy and the development of post-stroke seizures in the current study, Table 1. This finding could be of clinical significance in the management of ischemic stroke patients.

The present study found an association between post-stroke seizure occurrence with aphasia and symptoms of right-side weakness, Table 1. It is well established that language areas are predominantly located in the left hemisphere, the dominant hemisphere, in 95–99% of right-handed individuals and roughly 70% of left-handed individuals (Kelly et al. 2004). Interestingly, motor impairments on the right upper and lower sides were significantly associated with a higher rate of seizures. A contrasting finding revealed that patients exhibiting unilateral weakness were less prone to early seizures following a stroke (Alsaad et al. 2022). However, there was no statistically significant disparity in the rate of seizure among patients with left-limb motor impairment in the present study. The specific location of the brain injury plays a pivotal role in determining the timing and duration of post-stroke seizures (Loscher et al. 2015). Further research is necessary to explore which basic and clinical characteristics make patients with right-side weakness/aphasia more susceptible to post-stroke seizures. It is also important to determine whether the location of the stroke and its severity affect the incidence of post-stroke seizures in this group of patients.

As presented in Table 1; Fig. 2, the post-stroke seizure group had higher odds of developing complications such as pneumonia, cerebral edema, DVT-PE, and impaired consciousness. Stroke-associated pneumonia is a prevalent complication of acute ischemic stroke (Jitpratoom and Boonyasiri 2024). In the present study, 22.3% of ischemic stroke patients developed pneumonia and it was independently associated with post-stroke seizure. This finding is in alignment with a previous multicenter study linking the correlation between post-stroke seizure to stroke-associated pneumonia infection (Huang et al. 2014). In addition, the present study found a statistically significant independent association between the incidence of cerebral edema with post-stroke seizures, Fig. 2. A multicentric cohort study from the United Kingdom revealed that cerebral edema could serve as an additional independent marker for identifying patients with high prevalence of acute seizures. Recent research has explored the role of blood-brain barrier (BBB) dysfunction in pathogenesis and the onset of seizures and epilepsy (Bernardino et al. 2024). One possible explanation of these findings is that cerebral edema may have disrupted the BBB further, leading to seizures in ischemic stroke patients.

DVT and PE were observed in 17.4% of ischemic stroke patients who experienced post-stroke seizures and only in 6.7% of those who were seizure-free. Researchers have firmly established that the occurrence of DVT in the lower extremities is a common complication of acute ischemic stroke (Han et al. 2023). DVT can lead to PE, a life-threatening condition that accounts for 13–25% of early deaths after a stroke (Kelly et al. 2004). Our results aligned with a study conducted in Saudi Arabia, which reported that patients who suffered from ischemic stroke developed PE, and a significant number of them encountered early seizures (Alsaad et al. 2022). According to a recent study, seizures are thought to be a consequence of ischemic hypoxic encephalopathy resulting from PE (Leong et al. 2022). However, our study failed to document DVT-PE independent association with the occurrence of post-stroke seizure.

In the current study, HT, stroke recurrence, and death were assessed to explore the association between post-stroke seizures and major adverse effects post-stroke. Two previous studies have reported an independent association between HT and post-stroke seizure incidence (Procaccianti et al. 2012; Brondani et al. 2019). In contrast, after adjusting for covariates, our study’s logistic regression analysis found no significant association between HT and post-stroke seizures. In addition to HT, post-stroke seizures have been linked to higher mortality rates (Lahti et al. 2021). Similarly, a study from Saudi Arabia by Alsaad et al., reported a higher mortality rate in patients with early seizures, with those experiencing early seizures having more than double the risk of in-hospital death compared to those without (Alsaad et al. 2022). However, in our study, logistic regression analysis did not show a significant association between post-stroke seizures and mortality rates after adjusting for covariates. This variation may be attributed to differences in study design, stroke severity, stroke subtypes, cortical involvement, and comorbidities across study populations.

Lastly, the current study reported stroke recurrence to be independently associated with post-stroke seizure. Similar to our study, results from a study conducted in Sweden reported stroke recurrence as an independent predictor of seizure incidence (Redfors et al. 2020). In contrast, another multicentric study conducted with cohorts from Portugal, Colombia, and the Netherlands indicated that experiencing a stroke recurrence does not increase the frequency of acute symptomatic seizures (Leal Rato et al. 2024). We anticipate that variations in demographics, genetics, and underlying health conditions among populations in different countries may influence the risk of seizures after stroke. Factors such as age, prevalence of vascular risk factors, and comorbidities can vary significantly.

One of the limitations of this report was the retrospective nature of the study. In addition, due to limitations in data collection, specific data related to type of seizure, the exact median time for seizure occurrence, and the differentiation between post-stroke seizure and post-stroke epilepsy was not documented. Future studies should aim to provide more comprehensive insights by using extensive and diverse cohorts that include a larger sample size, ethnicities, and geographic regions. Additionally, it is advisable to conduct long-term follow-up studies to examine the long-term effects of stroke on the incidence and recurrence of seizures. Moreover, it is important to evaluate whether a subset of the population, by categorizing patients based on variables such as seizure type and characteristics, stroke initial severity, and age, may influence the rate of post-stroke seizure. This approach will help in understanding the temporal relationships involved.