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A seizure can be an early sign of acute stroke as well as a differential diagnosis. The clinical presentation of a seizure can be difficult to distinguish to those of an acute stroke, making them one of the most common “stroke mimics” [3]. Meanwhile, seizures “occurring in close temporal association with a documented brain insult” are called acute symptomatic seizures [6]. Among these acute symptomatic seizures after stroke, the subset of seizures occurring at the immediate onset of a stroke or during ongoing diagnostics and prior to acute treatment (“seizure at onset”, SaO) pose a diagnostic and therapeutic challenge for the treating physicians in particular and will therefore be the topic of this paper.