Introduction
Seizures are a major complication that can occur after a stroke, and seizures are also the most common symptom of adult epilepsy. In general, the incidence of seizures increases significantly when a hemorrhagic infarction occurs, when the lesion is located in the cerebral cortex, or when the lesion is large and severe. Seizures caused by stroke sequelae are called post-stroke seizures or post-stroke epilepsy [
1,
2].
Post-stroke seizures are defined as single or multiple convulsive episodes after a stroke which are associated with brain damage due to the stroke, regardless of the time of onset after the stroke. Post-stroke epilepsy refers to a seizure after a stroke and a diagnosis of epilepsy has been confirmed [
3]. Post-stroke seizures include early seizures and late seizures, depending on when they first occur. Early seizures occur within a week after the stroke, and late seizures occur 2 weeks or more after the stroke [
1,
2].
Post-stroke seizures are more common in patients with a cerebral hemorrhage compared with an ischemic stroke and they typically occur within 48 hours of the onset of stroke symptoms. Seizures after a brain hemorrhage are accompanied by worsening clinical symptoms, deviation of the body midline, and a reduced recovery from the brain hemorrhage, but the exact cause-effect relationship is still unclear [
2].
There are many studies on post-stroke epilepsy in Korea, but only 1 study in 2006 [
4] which mentioned Korean medical intervention. In this study combined Western-Korean medicine treatment was given to a post-stroke patient after surgical subdural hematoma drainage.
Discussion
The patient in this case report is a slender woman who had a pale complexion, stiff back and knees, and often felt fatigued, and urinated frequently due to diabetes. Based on these symptoms, the Korean medical diagnosis was Bishineumheo (lack of yin in the spleen and kidneys). The patient said that she had been performing rehabilitation exercise as recommended following hemiplegia surgery, but suddenly the seizures started. So, she had to stop her rehabilitation exercises. It was assumed that she may not recover due to lack of energy because she was in a Bisineumheo state. Dokhwajihwangtang is a drug derived from Yukmijihwangtang and is used for various symptoms caused by a prolonged Bisineumheo state. In Korean medicine, Saposhnikoviae Radix and Araliae Continentalis Radix relieve the symptoms of a stroke, and the pain and cramps in the musculoskeletal system, so these drugs were prescribed to the patient [
8]. On July 16
th, when the convulsive symptoms had disappeared, the patient slowly began her rehabilitation exercises. This patient would need more physical strength to exercise so Sipjeondaebotang was prescribed to the patient from July 29
th. Sipjeondaebotang has the effect of filling all the qi, blood, yin and yang in the whole body. It is also used for people who have lost stamina after surgery or due to a long illness [
9]. In fact, Dokhwajihwangtang is a medicine that corresponds to Soyangin in Sasang Constitutional Medicine, and Sipjeondaebotang is not a medicine for Soyangin because it contains ginseng and other warm herbs [
10,
11]. However, this patient needed energy for her rehabilitation exercises and she was in a state of weakness after her illness. Therefore, Sipjeondaebotang was prescribed for a short period of time, and the patient’s condition was carefully checked during the treatment period. There were no side effects after taking Sipjeondaebotang.
As described above, herbal medicine was prescribed according to the traditional Korean medical diagnosis system, and acupuncture treatment was basically performed for the purpose of relieving muscle tension in the areas of pain and promoting blood-qi circulation.
Chuna treatment promotes blood circulation, relieves muscle spasms, removes adhered muscles, and enhances metabolism. This patient’s neck turned to the left during seizures. The patient did not complain of neck pain, but the patient’s scalene muscle, sternocleidomastoid muscle, and trapezius muscle caused pain when they were palpated. Fascia relaxation therapy was performed focusing on these muscles, and the patient felt more comfortable after the chuna treatment [
12].
Remote wet cupping treatment was added to areas in the trunk where non-physiological blood stagnation and gas were suspected, such as Gansu (BL18), Bisu (BL20) and Jangmun (LR13).
The main treatments for seizure were herbal medicine, but there is no evidence of cause and effect. Further studies are needed to observe the effects of stroke and stroke in patients with convulsions after a stroke and brain surgery.
After surgical drainage of acute non-traumatic subdural hematoma on March 27th, the patient had symptoms of hemiplegia and a MMT Grade 4 on the right side. On June 26th, a simple partial seizure occurred, mainly causing symptoms of the right U/E. She had a brain CT after the seizure, but no additional lesions were observed. She was prescribed an anticonvulsant drug at the university hospital where the surgery was performed, but her symptoms remained the same. The daily dose of Clonazepam was increased from 0.5mg to 1mg but there was no improvement in symptoms. However, the frequency and severity of the seizures continued. The patient was admitted to the Korean medicine hospital on July 11th and received combined Korean medicine treatment.
After hospitalization, the frequency and intensity of convulsions gradually decreased, and as of July 15th, convulsions no longer occurred. From July 16th, the daily dose of Clonazepam was reduced from 0.5mg to 0.25mg. The patient was in a good condition, so on July 18th, the anticonvulsant medication was completely stopped. Bonaring A was also stopped on July 16th. Even after discontinuing these medications, the seizures did not recur, and the pain and weakness steadily improved until discharge.
Epilepsy after a stroke and brain surgery is well known. The diagnosis of epilepsy requires not only clinical symptoms, but also an magnetic resonance imaging and electroencephalogram of the brain [
3]. The patient in this case did not bring her electroencephalogram findings from the previous hospital and was taking only prescribed anticonvulsant and antiemetic drugs. The pattern of seizures corresponded to simple partial seizures.
Appropriate anticonvulsant medications are recommended for seizures after a cerebral hemorrhage or brain surgery. However, in the case of recurrent seizures or delayed seizures following intraparenchymal bleeding, a long-term medication plan is considered [
13].
Clonazepam is effective for up to 6 to 12 hours in adults [
14]. Therefore, it means that only Korean medicine was applied in the treatment of seizures from several days after stopping clonazepam. Even after stopping the anticonvulsant drug, all symptoms improved. However, it was not clear whether the herbal medicine played a role in the treatment of seizures, because this patient did not receive just herbal medicine from the beginning of the treatment at the Korean medicine hospital.
Anticonvulsants usually require long-term use and if symptoms improve, they are tapered over several weeks [
15,
16]. These drugs have various side effects. There is a 10–15% chance of serious side effects when using common anticonvulsants such as valproic acid or phenytoin. Therefore, anticonvulsant drugs are justified when the risk of seizures is at least 10%. A single seizure can be dangerous to the patient, or if the seizure causes serious disturbance to daily life, the use of anticonvulsant drugs is justified [
15]. Further studies are needed to determine whether anticonvulsant medications can be used in combination with Korean medicine treatments in patients with seizures after cerebral hemorrhage.
The limitations of this study are firstly, the patient’s electroencephalogram could not be confirmed after the convulsions had disappeared. Secondly, it’s not clear which treatment contributed to the cessation of the seizures because combined Korean medicine treatment was received. Thirdly, the patient’s post-discharge condition was not followed. In epilepsy, the probability of recurrence varies from 12% to 67% when the drug is stopped, and seizures occur frequently within the first year after stopping medication. Therefore, it is desirable that the patient’s condition be followed long-term after discharge [
17]. Fourthly, this study is limited by the patient number included in this case report.
This study is the first case report where Korean medicine has been used to treatment and manage seizures after a cerebral hemorrhage and brain surgery. However, further study of combined Western-Korean medicine treatment for seizures after a stroke or surgical brain surgery is necessary.