Insights into Risk Factors and Outcomes of Post-Stroke Seizures in Saudi Arabia: A Multicenter Analysis

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Alraddadi, Yasser Alatawi, Raju S. Kumar, Jawad I. Bukhari, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4968208/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Dec, 2024 Read the published version in Metabolic Brain Disease → Version 1 posted 9 You are reading this latest preprint version Abstract Objective: Post-stroke seizures present a global challenge, yet its frequency and factors associated with its incidence are poorly documented, particularly in the Middle East. Thus, this study aims to investigate post-stroke seizure frequency and stroke-associated factors among ischemic stroke patients in Saudi Arabia, addressing demographic, clinical, and comorbid aspects to improve prognosis, diagnosis, prevention, and management. Methods: A multicenter observational study included eligible patients who were categorized into those who developed seizures and those who did not. The primary outcome was the incidence of recurrent stroke and death within 12 months, whereas 30-day hemorrhagic transformation was considered a secondary outcome. Results: The study involved 1235 ischemic stroke patients, in which 13.5% developed post-stroke seizures. Patients with post-stroke seizures had more extended hospital stays, higher intensive care unit (ICU) admission rates, and a higher prevalence of comorbidities. Factors independently associated with post-stroke seizures included previous stroke history (OR=1.93; 1.35-2.75), ICU admission (OR=1.7; 1.15-2.5), and depression (OR=2.1; 1.38-3.30). Logistic regression revealed associations between post-stroke seizures and hemorrhagic transformation (OR=2.61; 1.70-4.00), stroke recurrence (OR=2.30; 1.58-3.36), and mortality (OR=1.89; 1.33-2.68). However, after adjusting for covariates, post-stroke seizures were significantly associated with stroke recurrence only (aOR=1.7; 1.11-2.63). Significance: Our study identifies notable associations and risk factors for post-stroke seizures in ischemic stroke patients. This underscores the importance of adopting a comprehensive approach to stroke care to enhance the prediction, prevention, and management of post-stroke seizures. Further research is warranted to validate these findings, enhance the understanding of post-stroke seizure mechanisms, and guide management strategies. Stroke Post-stroke seizures Right-Side Impairment Stroke Complications Stroke Mortality Figures Figure 1 Figure 2 Figure 3 1. Introduction Stroke is a significant health burden, with an increased global incidence rate of 70% over the last three decades (Collaborators GBDS. 2021 ). Stroke survivors, particularly older adults, are at a higher risk of developing spontaneous seizures (Lee et al. 2022 ). The reported incidence of post-stroke seizure varies widely between studies, ranging between 2% and 33% (Chang et al. 2022 ). Post-stroke seizures are associated with a severe decline in quality of life, longer hospitalization, and increased rates of morbidity and mortality (Huang et al. 2014 ) Therefore, early identification of seizure incidence and optimal management are essential to improve patients' care and quality of life. Currently, the factors associated with the incidence of post-stroke seizures are not well characterized. A previous systematic review of 37 studies exploring the risk factors, reported an association between post-stroke seizure and stroke severity, lesion size, lesion location, cortical involvement, hemorrhagic transformation, and atrial fibrillation (AF) (Feher et al. 2020 ). Except for those variables, studies exploring other potential risk factors reported inconsistent results. For instance, there is limited evidence linking co-morbidities, such as diabetes, hypertension, depression, dementia, and peripheral infection to post-stroke seizures (Galovic et al. 2021 ). Also, studies exploring the National Institutes of Health Stroke Scale (NIHSS) as a predictor of post-stroke seizure have mixed results (Labovitz et al. 2001 ; George et al. 2019 ). In addition, studies assessing the impact of seizure on clinical outcomes reported inconsistent findings, with some studies reporting seizure as a predictor for worse clinical outcomes, while other studies reported neutral findings (Feher et al. 2020 ). Reasons for inconsistent results regarding predictors of seizure incidence post-stroke could be small sample size, inconsistent diagnostic criteria, timing of the seizure, length of stay, and acute vs. late post-stroke seizure (Beghi et al. 2011 ). Given the current increase in life expectancy and the expected increase in the number of stroke patients, identifying the ischemic stroke population at high risk is crucial. This study is conducted to characterize and identify stroke-related risk factors associated with post-stroke seizures in a large cohort of patients. In addition, the association between post-stroke seizure with stroke signs and symptoms, complications, outcomes, and mortality rates were also explored. To our knowledge, this is the first study to correlate the incidence of post-stroke seizure with stroke signs and symptoms, including motor impairment, aphasia, and dysarthria. Similarly, this is the first study to compare the incidence of 12-month recurrent stroke and mortality between post-stroke seizure and control stroke patients. 2. Methodology 2.1. Study design A two-center observational study was conducted at King Abdulaziz Medical City (KAMC) in Jeddah and Riyadh, between January 2016 and September 2022. Electronic medical records (BESTCare® 2.0) were used to screen the eligible patients based on the inclusion and exclusion criteria. The patients were divided into two groups based on whether they were diagnosed with post-stroke seizures within 12 months of the stroke incident. All patients were followed from stroke incidence until discharge except for some variables, including pneumonia (followed for seven days after the stroke), hemorrhagic transformation (30 days), mortality (12 months), and stroke recurrence (12 months). Computerized tomography (CT), magnetic resonance Imaging (MRI), or both confirmed the diagnosis of ischemic stroke. The King Abdullah International Medical Research Center (KAIMRC) Institutional Review Board approved the study in Riyadh, Saudi Arabia (study number: NRC24R/115/02). Since this study is observational, informed consent was waived for patients, as we used de-identified retrospective data. 2.2. Study Participants Adults who are ≥ 18 years old arriving at the emergency room within seven days of stroke symptoms or were admitted at the incident time with confirmed ischemic stroke diagnosis using either MRI or CT scan. These patients will be categorized depending on whether they develop post-stroke seizures or post-stroke epilepsy within 12 months. Excluded patients comprise the ones with a history of seizures or epilepsy prior to stroke incidence, patients with a transient ischemic attack or hemorrhagic stroke, and transferred patients with missing admission data or patients with complicated cases, Fig. 1 . 2.3. Outcomes The primary outcome is the incidence of 12-month mortality in patients with ischemic stroke, and secondary outcomes are the incidence of 30-day hemorrhagic transformation and 12-month stroke recurrence. 2.4. Study Setting The study was conducted at two centers in Saudi Arabia under KAMC. KAMC is an academic referral tertiary care hospital with 509 beds in Jeddah and 690 beds in Riyadh. 2.5. Data Collection The data collected included demographic data, Body mass index (BMI), Stroke subtype, presence of prior stroke, initial stroke severity using National Institute of Health Stroke Scale (NIHSS), administering tissue plasminogen activator (tPA) or mechanical thrombectomy (MT), length of hospital stay, intensive care unit (ICU) admission, history of comorbidities (hypertension, diabetes mellitus, dyslipidemia, AF, dementia, or depression), stroke signs and symptoms (motor impairment, aphasia, and dysarthria), and stroke complications (pneumonia, cerebral edema, deep vein thrombosis-pulmonary embolism (DVT-PE), and impaired consciousness, hemorrhagic transformation, recurrent stroke, and mortality). 2.6. Statistical Analysis This study aimed to assess various factors associated with post-stroke seizures and their potential impact on patient outcomes. Descriptive statistics for categorical data were generated using percentages and frequency, while the mean and standard deviation or median and interquartile range were used for continuous data as appropriate. The differences in clinical and demographic variables based on post-stroke seizure status were evaluated using the chi-square test, t-test, and nonparametric statistics when appropriate. Subsequently, the relationship between post-stroke seizures and clinical and demographic variables was examined using multivariable binary logistic regression with the backward variable selection technique. Another multivariable binary logistic regression analysis was conducted to determine whether post-stroke seizures could predict post-stroke outcomes, such as death, stroke recurrence, and hemorrhagic transformation. The statistical analyses were performed using the SAS OnDemand for Academics software by SAS. 3. Results 3.1. Patient Characteristics A total of 1235 patients diagnosed with ischemic stroke were included in the current study. The patients had a mean age of 65.6 (± 12.6 years) and 61.7% were male. Table 1 presents the baseline and clinical characteristics of stroke patients where 13.5% of the patients developed post-stroke seizures. Most of the patients who developed seizures had either stroke subtype 1 or 5 (51% and 32%, respectively). Patients with seizures had twice more extended hospital stay (24.5 vs. 12.8 days, respectively; p < 0.0001), higher ICU admission rate (48.5% vs. 27.4%, respectively; p < 0.0001), and almost twice increase in the risk of AF (17.4% vs. 9.6%, respectively; p = 0.0023), dementia (10.2% vs. 5.3%, respectively; p = 0.0143), and depression (22.2% vs. 11.4%, respectively; p = 0.0001) incidents. Details about patients' characteristics are presented in Table 1 . 3.2. Stroke Characteristics Our analysis revealed that initial clinical stroke severity is associated with a higher risk of developing seizures (NIHSS = 8.8 ± 5.7 vs. 6.8 ± 5.4, respectively; p < 0.0001). Patients with impairments in their right upper and right lower limbs had significantly higher incidence of seizures than those without any right limb impairment (51.5% vs 39.5%; p = 0.0036 and 47.9% vs 39.0%, p = 0.03, respectively). Interestingly, patients with left limb impairment had no statistically significant difference in seizure incidence, Table 1 . Patients who experienced seizures after suffering a stroke were found to have a higher incidence of complications compared to those who did not have seizures. These complications included pneumonia (39.5% vs. 19.6%; p = 0.00001), cerebral edema (17.4% vs. 6.9%; p = 0.00001), DVT-PE (17.4% vs. 6.7%; p = 0.00001), and loss of consciousness (47.9% vs. 26.17%; p = 0.00001). 3.3. Factors associated with post-stroke seizure Individuals who had previously experienced a stroke are more likely to develop seizures than those who are experiencing their first-ever stroke (aOR = 1.93 [95% CI 1.35–2.75]; p = 0.0003). In addition, ICU admission was significantly correlated with seizure occurrence (aOR = 1.7 [95% CI 1.15–2.5]; p = 0.0073), Fig. 2 . Similarly, patients who have depression were nearly twice as likely to develop seizures compared to those without depression (OR = 2.1 [95% CI 1.38–3.30]; p = 0.0007), Fig. 2 . 3.4. Association between post-stroke seizure and stroke outcomes Figure 3 shows the mortality, recurrent stroke, and hemorrhagic transformation incidence rates among the study population and each group. Logistic regression analysis showed the incidence of post-stroke seizure was associated with hemorrhagic transformation (OR = 2.61 [95% CI 1.70–4.00]; P < 0.0001), stroke recurrence (OR = 2.30 [95% CI 1.58–3.36]; P < 0.0001), and mortality (OR = 1.89 [95% CI 1.33–2.68]; P = 0.0004), Table 2 . However, following adjustment for covariates, logistic regression analysis found only stroke recurrence significantly associated with seizure incidence (aOR = 1.7 [95% CI 1.11–2.62]; p = 0.0151) compared to the seizure free stroke. Whereas the incidence of hemorrhagic transformation (aOR = 1.4 [95% CI 0.84–2.33]; p = 0.1992) and mortality (aOR = 0.93 [95% CI 0.59–1.38]; p = 0.6311) were not associated with the incidence of post-stroke seizures, Table 2 . 4. Discussion This multicenter study investigated the incidence and burden of post-stroke symptomatic seizures in Saudi Arabia. The average age of participants was 65.6 ± 12.6 years, and 61.7% were male. In our 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 varies largely, ranging from 2.5–12% (Feher et al. 2020 ). This discrepancy could be explained by the heterogenicity in study design mainly by the differences in the inclusion period between stroke and seizure occurrence, ranging from 24 h to 30 days. The higher seizure prevalence found in our study is anticipated as the period of inclusion between stroke and seizure was longer than previous studies (12 months). Based on the Trial of ORG 10172 IN Acute Stroke Treatment (TOAST) classification (Amalia. 2023), in this 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 ). In addition, in our cohort, most of the patients who developed seizures had either stroke subtype 1 or 5, whereas patients who had stroke due to small vessel disease, cardioembolism, or other determined etiology were less likely to develop post-stroke seizure. History of previous strokes was present in 39.9% of the population, 55.1% of the seizure group, and 36.8% in the non-seizure group ( p < 0.0001; Table 1 ). Our study found an independent association between previous history of stroke and post-stroke seizure incidence (aOR = 1.93 [95% CI 1.35–2.75] p = 0.0003; Fig. 2 ). These findings align with a recent systematic reviews and meta-analyses, emphasizing a solid link between post-stroke seizures, 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 the severity of the stroke (Koton et al. 2022 ). The NIHSS score is the most frequently used scoring system worldwide to assess the severity of stroke. This study reports that NIHSS score at admission is significantly associated with developing post-stroke seizures. The results are consistent with other reports indicating higher initial NIHSS score is a predictor of post-stroke seizures (Alsaad et al. 2022 ; Zollner et al. 2022). ln addition, in the present study, 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 multivariate regression model, ICU admission (aOR = 1.70 [95% CI 1.15–2.50] p = 0.0073; Fig. 2 ) remained significantly correlated with post-stroke seizure incidence. 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, in light of comparing different stroke treatments along with their outcomes. There is a marked increase in post stroke seizures in patients using mechanical thrombectomy (MT) according to a research study conducted in the United States. Approximately 1 in 20 acute ischemic stroke patients treated with MT experienced seizures. Their study also found that the occurrence of seizures increased the chances of in-hospital death by two times (Lekoubou et al. 2023 ). In contrast, our study found that patients treated with MT were more prone to develop post-stroke seizures. This is in part owed to the larger vessels ischemic stroke are more severe in general (Tawil et al. 2016 ). Contrary to the former, thrombolysis using tPA remains the preferred and established treatment for ischemic stroke within a restricted time frame (Knecht et al. 2017 ). There was no statistically significant correlation between tPA therapy and the development of post-stroke seizures found in the current study. This finding could be appreciated as a pragmatic predictor in post stroke seizure outcomes. The current study reported depression, AF, and dementia to be significantly associated with the incidence of post-stroke seizure. Similarly, a recent study revealed that young individuals who experience stroke-related seizures have an increased risk of developing dementia compared to those who do not have seizures (Lekoubou et al. 2022 ). Nevertheless, our further multivariate regression model did not demonstrate a significant association between dementia and seizure incidence after stroke. Thus, this contradiction calls for investigations to confirm our findings. Depression is a common complication that frequently occurs after a stroke, but it is often undervalued. It is estimated that about one-third of stroke patients suffer from post-stroke depression (Lee et al. 2021 ). Interestingly, our multivariate regression analysis found seizure incidence after stroke to be independently associated with 2-fold higher odds of stroke associated depression, Fig. 2 . This is consistent with a previous study in which there were higher rates of depression in patients with post-stroke seizures (Huang et al. 2014 ). A substantial majority of patients in our study were diagnosed with both hypertension and DM with 81.7% and 73.7%, respectively. However, our analysis did not reveal a significant correlation between them and the occurrence of post-stroke seizures. This outcome is consistent with a meta-analysis study that also concluded that hypertension and DM are not independent risk factors for post-stroke seizures (Ma et al. 2021 ). Contrarily, an earlier study suggested a significant correlation between hypertension, DM, and the onset of early seizures (Shmuely et al. 2017 ). Due to these conflicting findings, further studies are essential to better understand the relationship. The present report found an association between seizure incidence after stroke with aphasia and symptoms of right-side weakness incidence. Interestingly, motor impairments on the right upper and lower sides were significantly associated with a higher incidence 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 seizure incidence 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 ). Variability in the extent, hemisphere affected, and localization of infarct among different patients could potentially account for the low seizure incidence in individuals with left limb motor impairment. Aphasia was present in 28.1% of all stroke patients. Consistent with prior studies, it is 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 ). This correlation aligns well with our findings, as the patients exhibited motor impairments on the right side of their body coupled with aphasia. This association suggests that the stroke may be situated in the brain's left hemisphere. Notably, there was an association between patients experiencing aphasia and the occurrence of post-stroke seizures where patients who had aphasia had a higher seizure prevalence rate (37.2% vs. 26.6%, respectively; p = 0.0028) than those who had no aphasia. One plausible hypothesis explaining the link between post-stroke seizures and aphasia could be the engagement of deep and terminal branches of the middle cerebral artery (Phan et al. 2022 ; Nogles and Galuska. 2024). As presented in Table 1 and 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 our study, 22.3% of ischemic stroke patients developed pneumonia. The probability of having pneumonia was higher in the post-stroke seizures group (39.5% vs. 19.6%, respectively; p < 0.0001). Multivariate analysis confirmed the independent association of pneumonia incidence in the seizure-experiencing group (aOR = 1.65 [95% CI 1.12–2.42] p = 0.0112; Fig. 2 ) 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 our study, we found a significant independent association between the incidence of cerebral edema (aOR = 1.87 [95% CI 1.12–2.13] p = 0.0174) with post-stroke seizures, Fig. 2 . Cerebral edema complication is significantly associated with ischemic stroke, known to result in heightened intracranial pressure, swift deterioration of neurological symptoms, and the potential for cerebral herniation (Gu et al. 2022 ). A multicentric cohort study from the United Kingdom revealed that cerebral edema could serve as an additional independent marker for identifying patients at a heightened risk of acute seizures. Recent research has explored the role of BBB dysfunction in pathogenesis and the onset of seizures and epilepsy (Bernardino et al. 2024 ). We hypothesize that in our study, cerebral edema may have disrupted the BBB, leading to seizures in ischemic stroke patients. Future studies are needed to further explore this hypothesis and whether brain infection could play a role in this potential association between cerebral edema and seizures following stroke. 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 (p < 0.0001). 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 align 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 post-stroke seizure incidence. A previous study documented recurrent stroke is not associated with the development of early seizure after stroke (Alsaad et al. 2022 ). These results conflict with our findings, where we found an independent association of recurrent stroke or multiple stroke incidence with post-stroke seizure incidence. It is possible that the differences in study design among the two studies, as the seizure was followed for different time periods after stroke (3 days vs. 365 days), and the inclusion of all types of strokes in their study, contributed to the differences seen in the studies. Further studies are needed to confirm our findings. 5. Conclusion Our investigation into post-stroke seizures among ischemic stroke patients uncovered notable associations and insights. Risk factors contributing to post-stroke seizures encompass advanced age, male gender, and specific stroke subtypes. Individuals with a history of stroke, as well as those with comorbidities such as AF, dementia, and depression, demonstrated a higher prevalence of seizures. The study indicated a potential link between language impairments and an elevated likelihood of post-stroke seizures. Moreover, complications such as pneumonia, cerebral edema, deep vein thrombosis, and pulmonary embolism exhibited significant associations with post-stroke seizures. Stroke recurrence, history of stroke, and ICU admission are independently associated with seizures after stroke. The research underscores the importance of adopting a comprehensive approach to stroke care, considering both clinical and comorbid factors to enhance the prediction, prevention, and management of post-stroke seizures. 6. Declarations 6.1. Availability of data and materials The data and material are available upon request. 6.2. Competing interests The authors declare that they have no competing interests. 6.3. Funding No fund was provided to conduct this study. 6.4. Authors' contributions Eman A. Alraddadi Leading writing and editing the manuscript final review, supervising the writing, approving the manuscript, and submitting the study; Yasser Alatawi: Conceptualization, formal analysis, review and approve the final manuscript; Raju S. Kumar: Writing and reviewing the manuscript, approval of final form of manuscript; Jawad I. Bukhari: Data curation, data cleaning, designing figure 1, review and accept the final form of the manuscript; Abdulrahman E. Alghamdi: Data curation, review and accept the final form of the manuscript; Shahad Lughbi: Data curation, review and accept the final form of the manuscript; Reema Alghamdi: Data curation, writing the discussion; Khalid Al Sulaiman: Conceptualization, review the study and approve the final manuscript; Faisal F. Alamri: Conceived the study, supervising study design and data collection, editing and approve the final form of the manuscript. References Amalia L. 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Prevalence and prognosis of seizures among patients undergoing mechanical thrombectomy for acute ischemic stroke: A look at pre-2015 aha/asa guidelines update regarding endovascular treatment. J Stroke Cerebrovasc Dis. 2023;32(5):107049. Leong W, Zhang Y, Huang X, et al. Seizure as the clinical presentation of massive pulmonary embolism: Case report and literature review. Front Med (Lausanne). 2022;9:980847. Loscher W, Hirsch LJ, Schmidt D. The enigma of the latent period in the development of symptomatic acquired epilepsy - Traditional view versus new concepts. Epilepsy Behav. 2015;52(Pt A):78-92. Ma S, Fan X, Zhao X, Wang K, Wang H, Yang Y. Risk factors for early-onset seizures after stroke: A systematic review and meta-analysis of 18 observational studies. Brain Behav. 2021;11(6):e02142. Misra S, Kasner SE, Dawson J, et al. Outcomes in Patients With Poststroke Seizures: A Systematic Review and Meta-Analysis. JAMA Neurol. 2023;80(11):1155-1165. Nogles TE, Galuska MA. Middle Cerebral Artery Stroke. In: StatPearls. Treasure Island (FL)2024. Phan J, Ramos M, Soares T, Parmar MS. Poststroke Seizure and Epilepsy: A Review of Incidence, Risk Factors, Diagnosis, Pathophysiology, and Pharmacological Therapies. Oxid Med Cell Longev. 2022;2022:7692215. Shmuely S, van der Lende M, Lamberts RJ, Sander JW, Thijs RD. The heart of epilepsy: Current views and future concepts. Seizure. 2017;44:176-183. Tawil SE, Cheripelli B, Huang X, et al. How many stroke patients might be eligible for mechanical thrombectomy? Eur Stroke J. 2016;1(4):264-271. Zollner JP, Misselwitz B, Kaps M, et al. National Institutes of Health Stroke Scale (NIHSS) on admission predicts acute symptomatic seizure risk in ischemic stroke: a population-based study involving 135,117 cases. Sci Rep. 2020;10(1):3779. Tables Table 1. Univariate analysis of patients’ characteristics by post-stroke seizure. Characteristics Total (N=1235) Missing Seizure P Yes (N=167) No (N=1068) Age, mean ± SD 65.5 ± 12.6 65.6 ± 13.7 65.5 ± 12.5 0.8668 Male, n (%) 762 (61.7) 0 101 (60.5) 661 (61.9) 0.7270 Stroke subtype, n (%) 140 0.0029 1 557 (50.9) 80 (51.3) 477 (50.8) 2 275 (25.1) 13 (8.3) 58 (6.2) 3 71 (6.5) 24 (15.4) 251 (26.7) 4 28 (2.6) 3 (1.9) 25 (2.7) 5 164 (15.0) 36 (23.1) 128 (13.6) History of stroke, n (%) 477 (39.3) 21 91 (55.1) 386 (36.8) <0.0001 Initial NIHSS, median (IQR) 6 (3-9) 7 (5-12) 6 (3-9) <0.0001 tPA therapy, n (%) 118 (9.6) 3 21 (12.6) 97 (9.1) 0.1569 Mechanical thrombectomy, n (%) 63 (5.1) 2 15 (9.0) 48 (4.5) 0.0145 Length of stay (days), mean ± SD 14.4 ± 28.9 24.5 ± 41.4 12.8 ± 26.1 <0.0001 ICU admission, n (%) 372 (30.2) 5 81 (48.5) 291 (27.4) <0.0001 History of comorbidities, n (%) Hypertension 1008 (81.7) 1 144 (86.2) 864 (81.0) 0.1027 Diabetes mellitus 909 (73.7) 1 129 (77.3) 780 (73.1) 0.2583 Dyslipidemia 556 (45.1) 1 74 (44.3) 482 (45.2) 0.8351 Atrial fibrillation 131 (10.6) 1 29 (17.4) 102 (9.6) 0.0023 Dementia 74 (6.0) 1 17 (10.2) 57 (5.3) 0.0143 Depression 158 (12.8) 2 37 (22.2) 121 (11.4) 0.0001 Stroke signs and symptoms, n (%) LL motor impairment 542 (44.4) 15 81 (49.1) 461 (43.7) 0.1947 LR motor impairment 489 (40.2) 19 79 (47.9) 410 (39.0) 0.0308 UL motor impairment 542 (44.3) 12 80 (48.5) 462 (43.7) 0.2466 UR motor impairment 501 (41.1) 17 85 (51.5) 416 (39.5) 0.0036 Aphasia 345 (28.1) 6 63 (37.2) 282 (26.6) 0.0028 Dysarthria 671 (54.4) 2 94 (56.3) 577 (54.1) 0.6023 Stroke-related complications, n (%) Pneumonia 275 (22.3) 0 66 (39.5) 209 (19.6) <0.0001 Cerebral edema 103 (8.4) 1 29 (17.4) 74 (6.9) <0.0001 DVT-PE 101 (8.2) 0 29 (17.4) 72 (6.7) <0.0001 Impaired consciousness 359 (29.1) 2 80 (47.9) 279 (26.17) <0.0001 BMI: Body mass index; DVT-PE: Deep vein thrombosis-pulmonary embolism; ICU: Intensive care unit; IQR: Interquartile range; LL: lower left; LR: lower right; NIHSS: National Institutes of Health Stroke Scale; SD: Standard deviation; tPA: Tissue-type plasminogen activator; UL: Upper left; UR: Upper right. Table 2. Association between post-stroke seizure and stroke outcome. Unadjusted Model Adjusted Model a OR 95% CI P OR 95% CI P Hemorrhagic transformation 2.61 1.70-4.00 <0.0001 1.40 0.84-2.33 0.1992 Stroke recurrence 2.30 1.58-3.36 <0.0001 1.70 1.11-2.62 0.0151 Death 1.89 1.33-2.68 0.0004 0.93 0.59-1.38 0.6311 a The models were adjusted for a history of stroke, seizure, atrial fibrillation, dementia, depression, mechanical thrombectomy, ICU admission, pneumonia, cerebral edema, DVT-PE, impaired consciousness, motor impairment, and aphasia Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 19 Dec, 2024 Read the published version in Metabolic Brain Disease → Version 1 posted Editorial decision: Revision requested 14 Oct, 2024 Reviews received at journal 13 Oct, 2024 Reviews received at journal 25 Sep, 2024 Reviewers agreed at journal 23 Sep, 2024 Reviewers agreed at journal 20 Sep, 2024 Reviewers invited by journal 20 Sep, 2024 Editor assigned by journal 20 Sep, 2024 Submission checks completed at journal 20 Sep, 2024 First submitted to journal 24 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4968208","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":366009868,"identity":"1a2729ba-02ef-478e-a936-994b074aaa6b","order_by":0,"name":"Eman A. 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Bukhari","email":"","orcid":"","institution":"King Saud bin Abdulaziz University for Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Jawad","middleName":"I.","lastName":"Bukhari","suffix":""},{"id":366009876,"identity":"d4311aac-5a89-44d4-b7fd-4b946d50809a","order_by":4,"name":"Abdulrahman E. Alghamdi","email":"","orcid":"","institution":"King Abdullah International Medical Research Center","correspondingAuthor":false,"prefix":"","firstName":"Abdulrahman","middleName":"E.","lastName":"Alghamdi","suffix":""},{"id":366009878,"identity":"c48463ac-7a68-43bf-880b-3246e3eb0c45","order_by":5,"name":"Shahad Lughbi","email":"","orcid":"","institution":"Jazan University","correspondingAuthor":false,"prefix":"","firstName":"Shahad","middleName":"","lastName":"Lughbi","suffix":""},{"id":366009879,"identity":"d784eece-490a-444f-aae6-ac9777ea3f54","order_by":6,"name":"Reema Alghamdi","email":"","orcid":"","institution":"King Saud bin Abdulaziz University for Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Reema","middleName":"","lastName":"Alghamdi","suffix":""},{"id":366009883,"identity":"430c1844-65fb-49cd-83e1-c9329952128f","order_by":7,"name":"Khalid Al Sulaiman","email":"","orcid":"","institution":"King Abdulaziz Medical City","correspondingAuthor":false,"prefix":"","firstName":"Khalid","middleName":"Al","lastName":"Sulaiman","suffix":""},{"id":366009885,"identity":"e8111b32-8bba-4f56-8646-028141cd1e7c","order_by":8,"name":"Faisal F. Alamri","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYDACdhBhICcnAaIZG0BkAgEtzGAtxsakamEwTpxBtBb+ZuanmysKDNJn9h9+JsG4o46Bnz3HgPFHDW4tEofZzG6eMTDInS2RZibBeOYwg2TPGwNmnmN4rDnMYHazweBP7jwJBjPpv20HGAxu5BgwM7Dh1iF/mP0bUItBuhz/8W8SjG11DPY3QA77h1uLwWEekC0GCdIMOUCHtTEzGEjkGDDwtuHWYniYpwykxXDmjJxiC8a2wzwSZ54VHObtw61F7nj7tpsNfwzkJc4f33gD6DA5/vbkjQ9/fMPjfXTAAyIOkKBhFIyCUTAKRgEWAADvq0rJMwvVRwAAAABJRU5ErkJggg==","orcid":"","institution":"King Saud bin Abdulaziz University for Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Faisal","middleName":"F.","lastName":"Alamri","suffix":""}],"badges":[],"createdAt":"2024-08-24 08:51:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4968208/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4968208/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11011-024-01508-3","type":"published","date":"2024-12-19T15:57:07+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70175056,"identity":"eaed6796-7466-427b-b246-7e1d9a188681","added_by":"auto","created_at":"2024-11-29 07:15:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":138310,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart of The Included Sample\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4968208/v1/6de00784735454998787ab81.png"},{"id":70176027,"identity":"2f1009a1-3e2f-4b5e-99b8-0fa49644a703","added_by":"auto","created_at":"2024-11-29 07:31:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":65417,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFactors associated with post-stroke seizure.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4968208/v1/c72eed4ef909fc38bf4ea5de.png"},{"id":70175343,"identity":"574cdd90-951b-4767-a1f0-c59f4759c2de","added_by":"auto","created_at":"2024-11-29 07:23:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":92367,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePost-stroke outcomes by seizure status.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4968208/v1/a60d7dbe8adc02681dbd6251.png"},{"id":72201919,"identity":"4f8d3ae8-44ea-4618-a006-03aff608caec","added_by":"auto","created_at":"2024-12-23 16:12:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1257562,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4968208/v1/c09bd504-eda2-499d-8b6b-6f4561830639.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Insights into Risk Factors and Outcomes of Post-Stroke Seizures in Saudi Arabia: A Multicenter Analysis","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eStroke is a significant health burden, with an increased global incidence rate of 70% over the last three decades (Collaborators GBDS. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Stroke survivors, particularly older adults, are at a higher risk of developing spontaneous seizures (Lee et al. \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The reported incidence of post-stroke seizure varies widely between studies, ranging between 2% and 33% (Chang et al. \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Post-stroke seizures are associated with a severe decline in quality of life, longer hospitalization, and increased rates of morbidity and mortality (Huang et al. \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) Therefore, early identification of seizure incidence and optimal management are essential to improve patients' care and quality of life.\u003c/p\u003e \u003cp\u003eCurrently, the factors associated with the incidence of post-stroke seizures are not well characterized. A previous systematic review of 37 studies exploring the risk factors, reported an association between post-stroke seizure and stroke severity, lesion size, lesion location, cortical involvement, hemorrhagic transformation, and atrial fibrillation (AF) (Feher et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Except for those variables, studies exploring other potential risk factors reported inconsistent results. For instance, there is limited evidence linking co-morbidities, such as diabetes, hypertension, depression, dementia, and peripheral infection to post-stroke seizures (Galovic et al. \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Also, studies exploring the National Institutes of Health Stroke Scale (NIHSS) as a predictor of post-stroke seizure have mixed results (Labovitz et al. \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; George et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In addition, studies assessing the impact of seizure on clinical outcomes reported inconsistent findings, with some studies reporting seizure as a predictor for worse clinical outcomes, while other studies reported neutral findings (Feher et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eReasons for inconsistent results regarding predictors of seizure incidence post-stroke could be small sample size, inconsistent diagnostic criteria, timing of the seizure, length of stay, and acute vs. late post-stroke seizure (Beghi et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Given the current increase in life expectancy and the expected increase in the number of stroke patients, identifying the ischemic stroke population at high risk is crucial. This study is conducted to characterize and identify stroke-related risk factors associated with post-stroke seizures in a large cohort of patients. In addition, the association between post-stroke seizure with stroke signs and symptoms, complications, outcomes, and mortality rates were also explored. To our knowledge, this is the first study to correlate the incidence of post-stroke seizure with stroke signs and symptoms, including motor impairment, aphasia, and dysarthria. Similarly, this is the first study to compare the incidence of 12-month recurrent stroke and mortality between post-stroke seizure and control stroke patients.\u003c/p\u003e"},{"header":"2. Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study design\u003c/h2\u003e \u003cp\u003eA two-center observational study was conducted at King Abdulaziz Medical City (KAMC) in Jeddah and Riyadh, between January 2016 and September 2022. Electronic medical records (BESTCare\u0026reg; 2.0) were used to screen the eligible patients based on the inclusion and exclusion criteria. The patients were divided into two groups based on whether they were diagnosed with post-stroke seizures within 12 months of the stroke incident. All patients were followed from stroke incidence until discharge except for some variables, including pneumonia (followed for seven days after the stroke), hemorrhagic transformation (30 days), mortality (12 months), and stroke recurrence (12 months).\u003c/p\u003e \u003cp\u003eComputerized tomography (CT), magnetic resonance Imaging (MRI), or both confirmed the diagnosis of ischemic stroke. The King Abdullah International Medical Research Center (KAIMRC) Institutional Review Board approved the study in Riyadh, Saudi Arabia (study number: NRC24R/115/02). Since this study is observational, informed consent was waived for patients, as we used de-identified retrospective data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Study Participants\u003c/h2\u003e \u003cp\u003eAdults who are \u0026ge;\u0026thinsp;18 years old arriving at the emergency room within seven days of stroke symptoms or were admitted at the incident time with confirmed ischemic stroke diagnosis using either MRI or CT scan. These patients will be categorized depending on whether they develop post-stroke seizures or post-stroke epilepsy within 12 months. Excluded patients comprise the ones with a history of seizures or epilepsy prior to stroke incidence, patients with a transient ischemic attack or hemorrhagic stroke, and transferred patients with missing admission data or patients with complicated cases, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Outcomes\u003c/h2\u003e \u003cp\u003eThe primary outcome is the incidence of 12-month mortality in patients with ischemic stroke, and secondary outcomes are the incidence of 30-day hemorrhagic transformation and 12-month stroke recurrence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Study Setting\u003c/h2\u003e \u003cp\u003eThe study was conducted at two centers in Saudi Arabia under KAMC. KAMC is an academic referral tertiary care hospital with 509 beds in Jeddah and 690 beds in Riyadh.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Data Collection\u003c/h2\u003e \u003cp\u003eThe data collected included demographic data, Body mass index (BMI), Stroke subtype, presence of prior stroke, initial stroke severity using National Institute of Health Stroke Scale (NIHSS), administering tissue plasminogen activator (tPA) or mechanical thrombectomy (MT), length of hospital stay, intensive care unit (ICU) admission, history of comorbidities (hypertension, diabetes mellitus, dyslipidemia, AF, dementia, or depression), stroke signs and symptoms (motor impairment, aphasia, and dysarthria), and stroke complications (pneumonia, cerebral edema, deep vein thrombosis-pulmonary embolism (DVT-PE), and impaired consciousness, hemorrhagic transformation, recurrent stroke, and mortality).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Statistical Analysis\u003c/h2\u003e \u003cp\u003eThis study aimed to assess various factors associated with post-stroke seizures and their potential impact on patient outcomes. Descriptive statistics for categorical data were generated using percentages and frequency, while the mean and standard deviation or median and interquartile range were used for continuous data as appropriate. The differences in clinical and demographic variables based on post-stroke seizure status were evaluated using the chi-square test, t-test, and nonparametric statistics when appropriate. Subsequently, the relationship between post-stroke seizures and clinical and demographic variables was examined using multivariable binary logistic regression with the backward variable selection technique. Another multivariable binary logistic regression analysis was conducted to determine whether post-stroke seizures could predict post-stroke outcomes, such as death, stroke recurrence, and hemorrhagic transformation. The statistical analyses were performed using the SAS OnDemand for Academics software by SAS.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Patient Characteristics\u003c/h2\u003e \u003cp\u003eA total of 1235 patients diagnosed with ischemic stroke were included in the current study. The patients had a mean age of 65.6 (\u0026plusmn;\u0026thinsp;12.6 years) and 61.7% were male. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the baseline and clinical characteristics of stroke patients where 13.5% of the patients developed post-stroke seizures. Most of the patients who developed seizures had either stroke subtype 1 or 5 (51% and 32%, respectively). Patients with seizures had twice more extended hospital stay (24.5 vs. 12.8 days, respectively; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), higher ICU admission rate (48.5% vs. 27.4%, respectively; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and almost twice increase in the risk of AF (17.4% vs. 9.6%, respectively; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0023), dementia (10.2% vs. 5.3%, respectively; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0143), and depression (22.2% vs. 11.4%, respectively; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0001) incidents. Details about patients' characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Stroke Characteristics\u003c/h2\u003e \u003cp\u003eOur analysis revealed that initial clinical stroke severity is associated with a higher risk of developing seizures (NIHSS\u0026thinsp;=\u0026thinsp;8.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7 vs. 6.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4, respectively; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Patients with impairments in their right upper and right lower limbs had significantly higher incidence of seizures than those without any right limb impairment (51.5% vs 39.5%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0036 and 47.9% vs 39.0%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03, respectively). Interestingly, patients with left limb impairment had no statistically significant difference in seizure incidence, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003ePatients who experienced seizures after suffering a stroke were found to have a higher incidence of complications compared to those who did not have seizures. These complications included pneumonia (39.5% vs. 19.6%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00001), cerebral edema (17.4% vs. 6.9%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00001), DVT-PE (17.4% vs. 6.7%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00001), and loss of consciousness (47.9% vs. 26.17%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Factors associated with post-stroke seizure\u003c/h2\u003e \u003cp\u003eIndividuals who had previously experienced a stroke are more likely to develop seizures than those who are experiencing their first-ever stroke (aOR\u0026thinsp;=\u0026thinsp;1.93 [95% CI 1.35\u0026ndash;2.75]; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0003). In addition, ICU admission was significantly correlated with seizure occurrence (aOR\u0026thinsp;=\u0026thinsp;1.7 [95% CI 1.15\u0026ndash;2.5]; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0073), Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Similarly, patients who have depression were nearly twice as likely to develop seizures compared to those without depression (OR\u0026thinsp;=\u0026thinsp;2.1 [95% CI 1.38\u0026ndash;3.30]; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0007), Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Association between post-stroke seizure and stroke outcomes\u003c/h2\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the mortality, recurrent stroke, and hemorrhagic transformation incidence rates among the study population and each group. Logistic regression analysis showed the incidence of post-stroke seizure was associated with hemorrhagic transformation (OR\u0026thinsp;=\u0026thinsp;2.61 [95% CI 1.70\u0026ndash;4.00]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), stroke recurrence (OR\u0026thinsp;=\u0026thinsp;2.30 [95% CI 1.58\u0026ndash;3.36]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and mortality (OR\u0026thinsp;=\u0026thinsp;1.89 [95% CI 1.33\u0026ndash;2.68]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0004), Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eHowever, following adjustment for covariates, logistic regression analysis found only stroke recurrence significantly associated with seizure incidence (aOR\u0026thinsp;=\u0026thinsp;1.7 [95% CI 1.11\u0026ndash;2.62]; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0151) compared to the seizure free stroke. Whereas the incidence of hemorrhagic transformation (aOR\u0026thinsp;=\u0026thinsp;1.4 [95% CI 0.84\u0026ndash;2.33]; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.1992) and mortality (aOR\u0026thinsp;=\u0026thinsp;0.93 [95% CI 0.59\u0026ndash;1.38]; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.6311) were not associated with the incidence of post-stroke seizures, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis multicenter study investigated the incidence and burden of post-stroke symptomatic seizures in Saudi Arabia. The average age of participants was 65.6\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6 years, and 61.7% were male. In our 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 varies largely, ranging from 2.5\u0026ndash;12% (Feher et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This discrepancy could be explained by the heterogenicity in study design mainly by the differences in the inclusion period between stroke and seizure occurrence, ranging from 24 h to 30 days. The higher seizure prevalence found in our study is anticipated as the period of inclusion between stroke and seizure was longer than previous studies (12 months).\u003c/p\u003e \u003cp\u003eBased on the Trial of ORG 10172 IN Acute Stroke Treatment (TOAST) classification (Amalia. 2023), in this 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. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). In addition, in our cohort, most of the patients who developed seizures had either stroke subtype 1 or 5, whereas patients who had stroke due to small vessel disease, cardioembolism, or other determined etiology were less likely to develop post-stroke seizure.\u003c/p\u003e \u003cp\u003eHistory of previous strokes was present in 39.9% of the population, 55.1% of the seizure group, and 36.8% in the non-seizure group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001; Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Our study found an independent association between previous history of stroke and post-stroke seizure incidence (aOR\u0026thinsp;=\u0026thinsp;1.93 [95% CI 1.35\u0026ndash;2.75] \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0003; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These findings align with a recent systematic reviews and meta-analyses, emphasizing a solid link between post-stroke seizures, heightened mortality, and severe disability in individuals with a prior history of stroke (Misra et al. \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePredicting the outcome following a stroke is mainly influenced by the severity of the stroke (Koton et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The NIHSS score is the most frequently used scoring system worldwide to assess the severity of stroke. This study reports that NIHSS score at admission is significantly associated with developing post-stroke seizures. The results are consistent with other reports indicating higher initial NIHSS score is a predictor of post-stroke seizures (Alsaad et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Zollner et al. 2022). ln addition, in the present study, 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 multivariate regression model, ICU admission (aOR\u0026thinsp;=\u0026thinsp;1.70 [95% CI 1.15\u0026ndash;2.50] \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0073; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) remained significantly correlated with post-stroke seizure incidence. 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. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMoreover, in light of comparing different stroke treatments along with their outcomes. There is a marked increase in post stroke seizures in patients using mechanical thrombectomy (MT) according to a research study conducted in the United States. Approximately 1 in 20 acute ischemic stroke patients treated with MT experienced seizures. Their study also found that the occurrence of seizures increased the chances of in-hospital death by two times (Lekoubou et al. \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In contrast, our study found that patients treated with MT were more prone to develop post-stroke seizures. This is in part owed to the larger vessels ischemic stroke are more severe in general (Tawil et al. \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Contrary to the former, thrombolysis using tPA remains the preferred and established treatment for ischemic stroke within a restricted time frame (Knecht et al. \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). There was no statistically significant correlation between tPA therapy and the development of post-stroke seizures found in the current study. This finding could be appreciated as a pragmatic predictor in post stroke seizure outcomes.\u003c/p\u003e \u003cp\u003eThe current study reported depression, AF, and dementia to be significantly associated with the incidence of post-stroke seizure. Similarly, a recent study revealed that young individuals who experience stroke-related seizures have an increased risk of developing dementia compared to those who do not have seizures (Lekoubou et al. \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Nevertheless, our further multivariate regression model did not demonstrate a significant association between dementia and seizure incidence after stroke. Thus, this contradiction calls for investigations to confirm our findings. Depression is a common complication that frequently occurs after a stroke, but it is often undervalued. It is estimated that about one-third of stroke patients suffer from post-stroke depression (Lee et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Interestingly, our multivariate regression analysis found seizure incidence after stroke to be independently associated with 2-fold higher odds of stroke associated depression, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. This is consistent with a previous study in which there were higher rates of depression in patients with post-stroke seizures (Huang et al. \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA substantial majority of patients in our study were diagnosed with both hypertension and DM with 81.7% and 73.7%, respectively. However, our analysis did not reveal a significant correlation between them and the occurrence of post-stroke seizures. This outcome is consistent with a meta-analysis study that also concluded that hypertension and DM are not independent risk factors for post-stroke seizures (Ma et al. \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Contrarily, an earlier study suggested a significant correlation between hypertension, DM, and the onset of early seizures (Shmuely et al. \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Due to these conflicting findings, further studies are essential to better understand the relationship.\u003c/p\u003e \u003cp\u003eThe present report found an association between seizure incidence after stroke with aphasia and symptoms of right-side weakness incidence. Interestingly, motor impairments on the right upper and lower sides were significantly associated with a higher incidence of seizures. A contrasting finding revealed that patients exhibiting unilateral weakness were less prone to early seizures following a stroke (Alsaad et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, there was no statistically significant disparity in seizure incidence 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. \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Variability in the extent, hemisphere affected, and localization of infarct among different patients could potentially account for the low seizure incidence in individuals with left limb motor impairment.\u003c/p\u003e \u003cp\u003eAphasia was present in 28.1% of all stroke patients. Consistent with prior studies, it is established that language areas are predominantly located in the left hemisphere, the dominant hemisphere, in 95\u0026ndash;99% of right-handed individuals and roughly 70% of left-handed individuals (Kelly et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). This correlation aligns well with our findings, as the patients exhibited motor impairments on the right side of their body coupled with aphasia. This association suggests that the stroke may be situated in the brain's left hemisphere. Notably, there was an association between patients experiencing aphasia and the occurrence of post-stroke seizures where patients who had aphasia had a higher seizure prevalence rate (37.2% vs. 26.6%, respectively; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0028) than those who had no aphasia. One plausible hypothesis explaining the link between post-stroke seizures and aphasia could be the engagement of deep and terminal branches of the middle cerebral artery (Phan et al. \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Nogles and Galuska. 2024).\u003c/p\u003e \u003cp\u003eAs presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, 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 our study, 22.3% of ischemic stroke patients developed pneumonia. The probability of having pneumonia was higher in the post-stroke seizures group (39.5% vs. 19.6%, respectively; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Multivariate analysis confirmed the independent association of pneumonia incidence in the seizure-experiencing group (aOR\u0026thinsp;=\u0026thinsp;1.65 [95% CI 1.12\u0026ndash;2.42] \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0112; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) 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. \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our study, we found a significant independent association between the incidence of cerebral edema (aOR\u0026thinsp;=\u0026thinsp;1.87 [95% CI 1.12\u0026ndash;2.13] \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0174) with post-stroke seizures, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Cerebral edema complication is significantly associated with ischemic stroke, known to result in heightened intracranial pressure, swift deterioration of neurological symptoms, and the potential for cerebral herniation (Gu et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). A multicentric cohort study from the United Kingdom revealed that cerebral edema could serve as an additional independent marker for identifying patients at a heightened risk of acute seizures. Recent research has explored the role of BBB dysfunction in pathogenesis and the onset of seizures and epilepsy (Bernardino et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). We hypothesize that in our study, cerebral edema may have disrupted the BBB, leading to seizures in ischemic stroke patients. Future studies are needed to further explore this hypothesis and whether brain infection could play a role in this potential association between cerebral edema and seizures following stroke.\u003c/p\u003e \u003cp\u003eDVT 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 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Researchers have firmly established that the occurrence of DVT in the lower extremities is a common complication of acute ischemic stroke (Han et al. \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). DVT can lead to PE, a life-threatening condition that accounts for 13\u0026ndash;25% of early deaths after a stroke (Kelly et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Our results align 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. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). According to a recent study, seizures are thought to be a consequence of ischemic hypoxic encephalopathy resulting from PE (Leong et al. \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, our study failed to document DVT-PE independent association with post-stroke seizure incidence.\u003c/p\u003e \u003cp\u003eA previous study documented recurrent stroke is not associated with the development of early seizure after stroke (Alsaad et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). These results conflict with our findings, where we found an independent association of recurrent stroke or multiple stroke incidence with post-stroke seizure incidence. It is possible that the differences in study design among the two studies, as the seizure was followed for different time periods after stroke (3 days vs. 365 days), and the inclusion of all types of strokes in their study, contributed to the differences seen in the studies. Further studies are needed to confirm our findings.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eOur investigation into post-stroke seizures among ischemic stroke patients uncovered notable associations and insights. Risk factors contributing to post-stroke seizures encompass advanced age, male gender, and specific stroke subtypes. Individuals with a history of stroke, as well as those with comorbidities such as AF, dementia, and depression, demonstrated a higher prevalence of seizures. The study indicated a potential link between language impairments and an elevated likelihood of post-stroke seizures. Moreover, complications such as pneumonia, cerebral edema, deep vein thrombosis, and pulmonary embolism exhibited significant associations with post-stroke seizures. Stroke recurrence, history of stroke, and ICU admission are independently associated with seizures after stroke. The research underscores the importance of adopting a comprehensive approach to stroke care, considering both clinical and comorbid factors to enhance the prediction, prevention, and management of post-stroke seizures.\u003c/p\u003e"},{"header":"6. Declarations","content":"\u003cp\u003e\u003cstrong\u003e6.1. Availability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data and material are available upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.2.\u003c/strong\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.3. Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo fund was provided to conduct this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.4. Authors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEman A. Alraddadi\u0026nbsp;Leading writing and editing the manuscript final review, supervising the writing, approving the manuscript, and submitting the study; Yasser Alatawi:\u0026nbsp;Conceptualization, formal analysis, review and approve the final manuscript; Raju S. Kumar:\u0026nbsp;Writing and reviewing the manuscript, approval of final form of manuscript; Jawad I. Bukhari:\u0026nbsp;Data curation, data cleaning, designing figure 1, review and accept the final form of the manuscript;\u0026nbsp;Abdulrahman E. Alghamdi:\u0026nbsp;Data curation, review and accept the final form of the manuscript;\u0026nbsp;Shahad Lughbi:\u0026nbsp;Data curation, review and accept the final form of the manuscript;\u0026nbsp;Reema Alghamdi:\u0026nbsp;Data\u0026nbsp;curation, writing the discussion;\u0026nbsp;Khalid Al Sulaiman:\u0026nbsp;Conceptualization, review the study and approve the final manuscript;\u0026nbsp;Faisal F. Alamri:\u0026nbsp;Conceived \u0026nbsp;the study, \u0026nbsp;supervising study design and data collection, editing and approve the final form of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAmalia L. 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Methods for stroke severity assessment by chart review in the Atherosclerosis Risk in Communities study. \u003cem\u003eSci Rep.\u0026nbsp;\u003c/em\u003e2022;12(1):12338.\u003c/li\u003e\n \u003cli\u003eLabovitz DL, Hauser WA, Sacco RL. Prevalence and predictors of early seizure and status epilepticus after first stroke. \u003cem\u003eNeurology.\u0026nbsp;\u003c/em\u003e2001;57(2):200-206.\u003c/li\u003e\n \u003cli\u003eLee CH, Jeon SH, Kim MJ, et al. Factors Affecting Post-Stroke Depression in Acute Ischemic Stroke Patients after 3 Months. \u003cem\u003eJ Pers Med.\u0026nbsp;\u003c/em\u003e2021;11(11).\u003c/li\u003e\n \u003cli\u003eLee SH, Aw KL, Banik S, Myint PK. Post-stroke seizure risk prediction models: a systematic review and meta-analysis. \u003cem\u003eEpileptic Disord.\u0026nbsp;\u003c/em\u003e2022;24(2):302-314.\u003c/li\u003e\n \u003cli\u003eLekoubou A, Ba DM, Nguyen C, et al. Poststroke Seizures and the Risk of Dementia Among Young Stroke Survivors. \u003cem\u003eNeurology.\u0026nbsp;\u003c/em\u003e2022;99(4):e385-e392.\u003c/li\u003e\n \u003cli\u003eLekoubou A, Colon YP, Bishu KG, Ngonde AT, Bonilha L, Ovbiagele B. Prevalence and prognosis of seizures among patients undergoing mechanical thrombectomy for acute ischemic stroke: A look at pre-2015 aha/asa guidelines update regarding endovascular treatment. \u003cem\u003eJ Stroke Cerebrovasc Dis.\u0026nbsp;\u003c/em\u003e2023;32(5):107049.\u003c/li\u003e\n \u003cli\u003eLeong W, Zhang Y, Huang X, et al. Seizure as the clinical presentation of massive pulmonary embolism: Case report and literature review. \u003cem\u003eFront Med (Lausanne).\u0026nbsp;\u003c/em\u003e2022;9:980847.\u003c/li\u003e\n \u003cli\u003eLoscher W, Hirsch LJ, Schmidt D. The enigma of the latent period in the development of symptomatic acquired epilepsy - Traditional view versus new concepts. \u003cem\u003eEpilepsy Behav.\u0026nbsp;\u003c/em\u003e2015;52(Pt A):78-92.\u003c/li\u003e\n \u003cli\u003eMa S, Fan X, Zhao X, Wang K, Wang H, Yang Y. Risk factors for early-onset seizures after stroke: A systematic review and meta-analysis of 18 observational studies. \u003cem\u003eBrain Behav.\u0026nbsp;\u003c/em\u003e2021;11(6):e02142.\u003c/li\u003e\n \u003cli\u003eMisra S, Kasner SE, Dawson J, et al. Outcomes in Patients With Poststroke Seizures: A Systematic Review and Meta-Analysis. \u003cem\u003eJAMA Neurol.\u0026nbsp;\u003c/em\u003e2023;80(11):1155-1165.\u003c/li\u003e\n \u003cli\u003eNogles TE, Galuska MA. Middle Cerebral Artery Stroke. In: \u003cem\u003eStatPearls.\u003c/em\u003e Treasure Island (FL)2024.\u003c/li\u003e\n \u003cli\u003ePhan J, Ramos M, Soares T, Parmar MS. Poststroke Seizure and Epilepsy: A Review of Incidence, Risk Factors, Diagnosis, Pathophysiology, and Pharmacological Therapies. \u003cem\u003eOxid Med Cell Longev.\u0026nbsp;\u003c/em\u003e2022;2022:7692215.\u003c/li\u003e\n \u003cli\u003eShmuely S, van der Lende M, Lamberts RJ, Sander JW, Thijs RD. The heart of epilepsy: Current views and future concepts. \u003cem\u003eSeizure.\u0026nbsp;\u003c/em\u003e2017;44:176-183.\u003c/li\u003e\n \u003cli\u003eTawil SE, Cheripelli B, Huang X, et al. How many stroke patients might be eligible for mechanical thrombectomy? \u003cem\u003eEur Stroke J.\u0026nbsp;\u003c/em\u003e2016;1(4):264-271.\u003c/li\u003e\n \u003cli\u003eZollner JP, Misselwitz B, Kaps M, et al. National Institutes of Health Stroke Scale (NIHSS) on admission predicts acute symptomatic seizure risk in ischemic stroke: a population-based study involving 135,117 cases. \u003cem\u003eSci Rep.\u0026nbsp;\u003c/em\u003e2020;10(1):3779.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Univariate analysis of patients\u0026rsquo; characteristics by post-stroke seizure.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"562\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=1235)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMissing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeizure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=167)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=1068)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge,\u0026nbsp;\u003c/strong\u003emean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e65.5 \u0026plusmn; 12.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e65.6 \u0026plusmn; 13.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e65.5 \u0026plusmn; 12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.8668\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale,\u0026nbsp;\u003c/strong\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e762 (61.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e101 (60.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e661 (61.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.7270\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStroke subtype,\u0026nbsp;\u003c/strong\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0029\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e557 (50.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e80 (51.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e477 (50.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e275 (25.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e13 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e58 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e71 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e24 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e251 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e28 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e25 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e164 (15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e36 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e128 (13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of stroke,\u0026nbsp;\u003c/strong\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e477 (39.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e91 (55.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e386 (36.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitial NIHSS,\u0026nbsp;\u003c/strong\u003emedian (IQR)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e6 (3-9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e7 (5-12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e6 (3-9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003etPA therapy,\u0026nbsp;\u003c/strong\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e118 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e21 (12.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e97 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.1569\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMechanical thrombectomy,\u0026nbsp;\u003c/strong\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e63 (5.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e15 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e48 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0145\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of stay (days),\u0026nbsp;\u003c/strong\u003emean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e14.4 \u0026plusmn; 28.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e24.5 \u0026plusmn; 41.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e12.8 \u0026plusmn; 26.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eICU admission,\u0026nbsp;\u003c/strong\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e372 (30.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e81 (48.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e291 (27.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of comorbidities,\u0026nbsp;\u003c/strong\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 347px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypertension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1008 (81.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e144 (86.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e864 (81.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.1027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Diabetes mellitus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e909 (73.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e129 (77.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e780 (73.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.2583\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDyslipidemia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e556 (45.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e74 (44.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e482 (45.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.8351\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAtrial fibrillation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e131 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e29 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e102 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0023\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDementia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e74 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e17 (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e57 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0143\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepression\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e158 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e37 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e121 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStroke signs and symptoms,\u0026nbsp;\u003c/strong\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 347px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLL motor impairment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e542 (44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e81 (49.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e461 (43.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.1947\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLR motor impairment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e489 (40.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e79 (47.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e410 (39.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0308\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUL motor impairment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e542 (44.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e80 (48.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e462 (43.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.2466\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUR motor impairment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e501 (41.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e85 (51.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e416 (39.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0036\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAphasia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e345 (28.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e63 (37.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e282 (26.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0028\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDysarthria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e671 (54.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e94 (56.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e577 (54.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.6023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStroke-related complications,\u0026nbsp;\u003c/strong\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 347px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePneumonia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e275 (22.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e66 (39.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e209 (19.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCerebral edema\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e103 (8.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e29 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e74 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDVT-PE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e101 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e29 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e72 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImpaired consciousness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e359 (29.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e80 (47.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e279 (26.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eBMI: Body mass index; DVT-PE: Deep vein thrombosis-pulmonary embolism; ICU: Intensive care unit; IQR: Interquartile range; LL: lower left; LR: lower right; NIHSS: National Institutes of Health Stroke Scale; SD: Standard deviation; tPA: Tissue-type plasminogen activator; UL: Upper left; UR: Upper right.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cstrong\u003eTable 2. Association between post-stroke seizure and stroke outcome.\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"581\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.759%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 27.883%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadjusted Model\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 32.358%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted Model \u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.759%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.54045%;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1876%;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.1549%;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.2203%;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3597%;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.77797%;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.759%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemorrhagic transformation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.54045%;\"\u003e\n \u003cp\u003e2.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1876%;\"\u003e\n \u003cp\u003e1.70-4.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.1549%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.2203%;\"\u003e\n \u003cp\u003e1.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3597%;\"\u003e\n \u003cp\u003e0.84-2.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.77797%;\"\u003e\n \u003cp\u003e0.1992\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.759%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStroke recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.54045%;\"\u003e\n \u003cp\u003e2.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1876%;\"\u003e\n \u003cp\u003e1.58-3.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.1549%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.2203%;\"\u003e\n \u003cp\u003e1.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3597%;\"\u003e\n \u003cp\u003e1.11-2.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.77797%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0151\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.759%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDeath\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.54045%;\"\u003e\n \u003cp\u003e1.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1876%;\"\u003e\n \u003cp\u003e1.33-2.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.1549%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.2203%;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3597%;\"\u003e\n \u003cp\u003e0.59-1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.77797%;\"\u003e\n \u003cp\u003e0.6311\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003csup\u003ea\u0026nbsp;\u003c/sup\u003eThe models were adjusted for a history of stroke, seizure, atrial fibrillation, dementia, depression, mechanical thrombectomy, ICU admission, pneumonia, cerebral edema, DVT-PE, impaired consciousness, motor impairment, and aphasia\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"metabolic-brain-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mebr","sideBox":"Learn more about [Metabolic Brain Disease](https://www.springer.com/journal/11011)","snPcode":"11011","submissionUrl":"https://submission.nature.com/new-submission/11011/3","title":"Metabolic Brain Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Stroke, Post-stroke seizures, Right-Side Impairment, Stroke Complications, Stroke Mortality ","lastPublishedDoi":"10.21203/rs.3.rs-4968208/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4968208/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e Post-stroke seizures present a global challenge, yet its frequency and factors associated with its incidence are poorly documented, particularly in the Middle East. Thus, this study aims to investigate post-stroke seizure frequency and stroke-associated factors among ischemic stroke patients in Saudi Arabia, addressing demographic, clinical, and comorbid aspects to improve prognosis, diagnosis, prevention, and management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A multicenter observational study included eligible patients who were categorized into those who developed seizures and those who did not. The primary outcome was the incidence of recurrent stroke and death within 12 months, whereas 30-day hemorrhagic transformation was considered a secondary outcome.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The study involved 1235 ischemic stroke patients, in which 13.5% developed post-stroke seizures. Patients with post-stroke seizures had more extended hospital stays, higher intensive care unit (ICU) admission rates, and a higher prevalence of comorbidities. Factors independently associated with post-stroke seizures included previous stroke history (OR=1.93; 1.35-2.75), ICU admission (OR=1.7; 1.15-2.5), and depression (OR=2.1; 1.38-3.30). Logistic regression revealed associations between post-stroke seizures and hemorrhagic transformation (OR=2.61; 1.70-4.00), stroke recurrence (OR=2.30; 1.58-3.36), and mortality (OR=1.89; 1.33-2.68). However, after adjusting for covariates, post-stroke seizures were significantly associated with stroke recurrence only (aOR=1.7; 1.11-2.63).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSignificance:\u003c/strong\u003e Our study identifies notable associations and risk factors for post-stroke seizures in ischemic stroke patients. This underscores the importance of adopting a comprehensive approach to stroke care to enhance the prediction, prevention, and management of post-stroke seizures. Further research is warranted to validate these findings, enhance the understanding of post-stroke seizure mechanisms, and guide management strategies.\u003c/p\u003e","manuscriptTitle":"Insights into Risk Factors and Outcomes of Post-Stroke Seizures in Saudi Arabia: A Multicenter Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-29 07:15:29","doi":"10.21203/rs.3.rs-4968208/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-14T22:24:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-14T01:50:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-25T17:16:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"281445219027980303900758634681837812636","date":"2024-09-23T23:43:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"110633619239272990131357832756598447285","date":"2024-09-20T20:29:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-20T16:29:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-20T06:53:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-20T06:52:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"Metabolic Brain Disease","date":"2024-08-24T08:49:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"metabolic-brain-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mebr","sideBox":"Learn more about [Metabolic Brain Disease](https://www.springer.com/journal/11011)","snPcode":"11011","submissionUrl":"https://submission.nature.com/new-submission/11011/3","title":"Metabolic Brain Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"1f3a4b83-1444-49a2-9b62-ee321b1c9a02","owner":[],"postedDate":"November 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T16:04:24+00:00","versionOfRecord":{"articleIdentity":"rs-4968208","link":"https://doi.org/10.1007/s11011-024-01508-3","journal":{"identity":"metabolic-brain-disease","isVorOnly":false,"title":"Metabolic Brain Disease"},"publishedOn":"2024-12-19 15:57:07","publishedOnDateReadable":"December 19th, 2024"},"versionCreatedAt":"2024-11-29 07:15:29","video":"","vorDoi":"10.1007/s11011-024-01508-3","vorDoiUrl":"https://doi.org/10.1007/s11011-024-01508-3","workflowStages":[]},"version":"v1","identity":"rs-4968208","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4968208","identity":"rs-4968208","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}