Post Stroke Epilepsy: Epidemiology, Risk Factors, Prevention, Management, and Future Directions

Abstract Purpose of Review Post-stroke epilepsy (PSE) is an increasingly important cause of long-term neurologic morbidity, healthcare utilization, and reduced quality of life among stroke survivors. This review summarizes current understanding of post-stroke epileptogenesis, clinical risk factors, predictive models, prevention strategies, and emerging approaches to individualized risk assessment. Recent Findings Post-stroke epileptogenesis involves evolving molecular, inflammatory, and structural changes across the acute, latent, and chronic phases of cerebral injury. Although risk factors vary by stroke subtype, early seizures, cortical involvement, greater stroke severity, hemorrhagic transformation, and large-vessel-territory infarction are consistently associated with PSE. Prognostic tools, including SeLECT, SeLECT 2.0, SeLECT-EEG, and CAVE, have improved risk stratification, although predictive accuracy remains limited. Randomized studies have not demonstrated a clear benefit of prophylactic antiseizure medications for preventing PSE. However, emerging observational evidence suggests that statins, angiotensin receptor blockers, and glucagon-like peptide-1 receptor agonists may have antiepileptogenic properties, warranting prospective evaluation. Summary Current management remains focused on treating seizures after PSE develops. Future progress will depend on improving prediction through the integration of electrophysiologic, imaging, and genetic biomarkers and applying artificial intelligence–based approaches, including machine-learning models and digital twins. These advances may enable individualized risk assessment, identify candidates for clinical trials, and guide targeted preventive interventions.