Previously we reported that early initiation of apixaban after acute ischemic stroke (AIS) due to atrial fibrillation (AF) demonstrated a similar patient safety profile when compared to later initiation of warfarin. Concomitant use of other medical therapies, such as initiation of anti-seizure medication (ASM) in this population, needs exploration.

Post-stroke epilepsy is the most common cause of epilepsy in older adults, and stroke due to AF is a major cause of cortical injury that can produce focal, structural epilepsy.

The AREST study (Apixaban for Early Prevention of Recurrent Embolic Stroke and Hemorrhagic Transformation), was a randomized controlled trial of early apixaban versus later warfarin in patients with AF and Transient Ischemic Attack (TIA), small-sized AIS, or medium-sized AIS, from 2015 to 2019.  An IRB-approved sub-study of AREST subjects enrolled at our institution was designed to review the use of ASM in this population.

After excluding prior ASM users, 8% (6/78) of AREST subjects were newly initiated on ASM. There was no statistically significant difference in stroke size, initial stroke severity (NIHSS), thrombolytic administration, endovascular intervention, or hemorrhagic transformation rates between the ASM and non-ASM groups. However, ASM patients were significantly older (87±9 vs. 73±12 years, p<0.01). There was a statistically significant higher proportion of patients initiated on ASM who reported prior symptoms or diagnosis of congestive heart failure (CHF) (50% vs. 9.7%, p<0.05). At day 14, the modified Rankin scale of disability was statistically significantly higher in the ASM versus non-ASM group (median 3.5 vs 1, p<0.05).