Pearls & Oy-sters: De Novo Seizure and Stroke in the Elderly

Seizures immediately preceding the occurrence of an ischemic or hemorrhagic stroke are a rare but well-documented phenomenon, for which the term “heraldic seizure” has been proposed. Cerebrovascular disease is the most common cause of epileptic seizures in elderly patients; thus, screening and management of vascular risk factors should be performed systematically in cases of late-onset epilepsy. MRI may help to distinguish heraldic seizure from stroke-elicited seizure by showing abnormalities confined to the cortex that spare vascular territories, increased magnetic resonance angiography flow in the ipsilateral cerebral arteries, and enhancement of the leptomeninges on postcontrast MRI. We present a case report that illustrates the difficulty of making the diagnosis of a heraldic seizure at onset.