Outcome of medically treated stroke associated with stenosis or occlusion of the internal carotid artery.
Authors: P. Bradshaw, E. Casey
Journal: BMJ (1967)

BRITISH 201in the internal environment that become more extreme with increasing age owing to decreased homoeostasis.Of the 10 patients with post-hemiplegic epilepsy whose cases are described above six are still definitely living, one surviving for ten years.Of the four remaining cases Case 2 died two years after the onset of symptoms, Case 4 died six months after the onset of symptoms, and Case 6 died four years after the onset of symptoms.We have been unable to trace the fate of one of the remaining cases.It is important to recognize that this condition responds extremely well to anticonvulsants.Since becoming interested in this subject I have found increasing numbers of epileptic syndromes occurring in this group of patients, and in view of the sequelae of intermittent confusion and paralysis the question of prophylactic anticonvulsants must be seriously considered in cases of hemiplegia secondary to cerebrovascular disease.It will in due course be necessary to have extensive trials in order to discover whether such an approach could prevent unnecessary invalidism and hospitalization.Finally a word about treatment.In the cases which I have so far treated phenytoin has been the drug of choice.This drug, even in small doses, has in most cases brought dramatic improvement.In one case of sensory epilepsy larger doses were needed.This patient had sensory signs, and conformed rather more closely with the concept of thalamic pain.Since adopting this approach of anticonvulsant therapy to patients with post-hemiplegic pain I have so far not found anyone with this condition who did not respond to anticonvul- sants.Post-hemiplegic epilepsy occurs sometimes at night only.In this group phenobarbitone given at night is the drug of choice.The use of phenobarbitone as a routine anticonvulsant in old people is likely to be fraught with the dangers of intoxi- cation due to cumulation if there is impaired renal function. ConclusionsEpilepsy in the elderly is a relatively common condition and and is usually caused by cerebrovascular disease.Epilepsy occurring after hemiplegia may present with motor manifestations, sensory manifestations, or confusion, and may be misdiagnosed as a fresh cerebrovascular accident, thalamic pain, or senile dementia.Post-hemiplegic pain, which has hitherto been regarded as intractable in many cases, may respond to treatment with anti- convulsant drugs.It is suggested that the routine use of anticonvulsants in patients who have had cerebral thrombosis may in the future be regarded as justifiable. SummaryTen patients suffering from post-hemiplegic epilepsy are described.They fall into two clinical categories: (1) motor manifestations ;(2) sensorimotor manifestations.Motor manifestations can be confused with fresh cerebrovascular accidents, and it is demonstrated that the sensory mani- festations can be associated with pain severe enough to be confused with pain of thalamic origin.The prognosis of post-hemiplegic epilepsy is discussed.It is emphasized that the occurrence of this condition, if recog- nized, is not necessarily of serious import provided the correct treatment is instituted.It is probable that post-hemiplegic epilepsy is relatively common.Phenytoin is the drug of choice in treatment.Phenobarbitone as a routine anticonvulsant is contraindicated in old people.A routine course of anticonvulsants for patients who have had cerebral thromboses may in the future be regarded as justifiable.