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posttraumatic_epilepsy

Posttraumatic epilepsy

Epidemiology

Traumatic brain injury (TBI) is one of the most common causes of acquired epilepsy, and posttraumatic epilepsy (PTE) results in significant somatic and psychosocial morbidity.

The incidence of early post-traumatic seizures after civilian traumatic brain injury ranges 4-25%.

The true incidence of PTE in children is still uncertain, because most research has been based primarily on adults.

see Posttraumatic epilepsy in children.

Risk

The risk of developing PTE relates directly to TBI severity, but the latency to first seizure can be decades after the inciting trauma. Given this “silent period,” much work has focused on identification of molecular and radiographic biomarkers for risk stratification and on development of therapies to prevent epileptogenesis.

Research suggests that there are reciprocal relationships between mental health (MH) disorders and epilepsy risk.

Data suggest that PTE is associated with mental health (MH) outcomes 2years after TBI, findings whose significance may reflect reciprocal, biological, psychological, and/or experiential factors contributing to and resulting from both PTE and MH status post-TBI. Future work should consider temporal and reciprocal relationships between PTE and MH as well as if/how treatment of each condition influences biosusceptibility to the other condition 1).

Prevention

Treatment

Clinical management requires vigilant neurologic surveillance and recognition of the heterogeneous endophenotypes associated with PTE.

Appropriate treatment of patients who have or are at risk for seizures varies as a function of time after TBI, and the clinician's armamentarium includes an ever-expanding diversity of pharmacological and surgical options.


Most recently, neuromodulation with implantable devices has emerged as a promising therapeutic strategy for some patients with refractory PTE 2).

Case series

2016

In a retrospective multicenter cohort study including 5 regional pediatric trauma centers affiliated with academic medical centers, the authors examined data from 236 children (age < 18 years) with severe traumatic brain injury (TBI) (admission Glasgow Coma Scale score ≤ 8, ICD-9 diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head Abbreviated Injury Scale score ≥ 3) who received tracheal intubation for ≥ 48 hours in the ICU between 2007 and 2011.

Of 236 patients, 187 (79%) received seizure prophylaxis. In 2 of the 5 centers, 100% of the patients received seizure prophylaxis medication. Use of seizure prophylaxis was associated with younger patient age (p < 0.001), inflicted TBI (p < 0.001), subdural hematoma (p = 0.02), cerebral infarction (p < 0.001), and use of electroencephalography (p = 0.023), but not higher Injury Severity Score. In 63% cases in which seizure prophylaxis was used, the patients were given the first medication within 24 hours of injury, and 50% of the patients received the first dose in the prehospital or emergency department setting. Initial seizure prophylaxis was most commonly with fosphenytoin (47%), followed by phenytoin (40%).

While fosphenytoin was the most commonly used medication for seizure prophylaxis, there was large variation within and between trauma centers with respect to timing and choice of seizure prophylaxis in severe pediatric TBI. The heterogeneity in seizure prophylaxis use may explain the previously observed lack of relationship between seizure prophylaxis and outcomes 3).

1)
Juengst SB, Wagner AK, Ritter AC, Szaflarski JP, Walker WC, Zafonte RD, Brown AW, Hammond FM, Pugh MJ, Shea T, Krellman JW, Bushnik T, Arenth PM. Post-traumatic epilepsy associations with mental health outcomes in the first two years after moderate to severe TBI: A TBI Model Systems analysis. Epilepsy Behav. 2017 Jun 25;73:240-246. doi: 10.1016/j.yebeh.2017.06.001. [Epub ahead of print] PubMed PMID: 28658654.
2)
Rao VR, Parko KL. Clinical Approach to Posttraumatic Epilepsy. Semin Neurol. 2015 Feb;35(1):57-63. Epub 2015 Feb 25. PubMed PMID: 25714868.
3)
Ostahowski PJ, Kannan N, Wainwright MS, Qiu Q, Mink RB, Groner JI, Bell MJ, Giza CC, Zatzick DF, Ellenbogen RG, Boyle LN, Mitchell PH, Vavilala MS; PEGASUS (Pediatric Guideline Adherence and Outcomes) Study.. Variation in seizure prophylaxis in severe pediatric traumatic brain injury. J Neurosurg Pediatr. 2016 Oct;18(4):499-506. PubMed PMID: 27258588.
posttraumatic_epilepsy.txt · Last modified: 2018/11/26 08:44 by administrador