Post-Stroke Epilepsy After Pediatric Arterial Ischemic Stroke: Incidence and Risk Factors—A Narrative Review

Abstract

Highlights What are the main findings? Approximately one in four children who experience an arterial ischemic stroke will eventually develop epilepsy, although reported incidence varies widely across studies (7% to >40%). Acute symptomatic seizures, particularly very early seizures and status epilepticus, are the strongest predictors of post-stroke epilepsy (≈4-fold increased risk), while age, cortical involvement, greater lesion burden, persistent neurological deficits, and possibly genetic and biological factors further increase risk. What are the implications of the main findings? Children presenting with acute symptomatic seizures and other high-risk clinical or radiological features should undergo closer long-term surveillance for the early identification and management of post-stroke epilepsy. Improved risk stratification may support personalized follow-up strategies and stimulate research into preventive interventions targeting potentially modifiable factors, such as vitamin D deficiency, and genetic susceptibility. Abstract Background/Objectives: Post-stroke epilepsy represents one of the most frequent and impactful long-term sequelae of pediatric arterial ischemic stroke. Children are particularly vulnerable to developing seizures and epilepsy after stroke, likely because the immature brain responds differently to ischemic injury than the adult brain. The purpose of this narrative review is to summarize the current evidence regarding the epidemiology, risk factors, mechanisms, and clinical implications of post-stroke epilepsy following pediatric arterial ischemic stroke. Methods: We conducted a narrative review to examine the incidence, determinants, risk stratification, and long-term outcomes of post-stroke epilepsy following childhood arterial ischemic stroke beyond the neonatal period. Results: The reported incidence of post-stroke epilepsy in children varies considerably across studies, ranging from approximately 7% to over 40%. However, recent data suggest that roughly one in four children who experience an arterial ischemic stroke will eventually develop epilepsy, highlighting the substantial long-term burden of this condition. Acute symptomatic seizures, particularly very early seizures and acute status epilepticus, consistently emerge as the strongest predictors of subsequent epilepsy, with recent pediatric meta-analytic data suggesting an approximately fourfold increased risk of post-stroke epilepsy. Cortical involvement and persistent neurological deficits also represent robust predictors of post-stroke epilepsy (PSE), whereas younger age at stroke onset, multifocal infarctions, greater infarct burden, anterior circulation involvement, and focal cerebral arteriopathy have been associated with an increased risk. Emerging evidence further suggests a possible contribution of genetic susceptibility and potentially modifiable biological factors, such as vitamin D deficiency, to epileptogenic risk. Conclusions: This narrative review summarizes current evidence regarding the incidence, determinants, and pathophysiological mechanisms of post-stroke epilepsy following childhood arterial ischemic stroke, highlighting established and emerging risk factors and their implications for long-term risk stratification, clinical management, and future preventive strategies.