Posttraumatic seizures

..

Post trauma serizures

I Impact seizures : within 24 hours
II Early seizures : within 1 week

III Late seizures : more than 8 days

Sequence of seizures
: Hypoxia

: Increased metabolic demand

: Metabolic changes : Excess neurotransmitter release

: Hypertension : Increased IC hypertension : Unconscious

Incidence :
PTE

related to severity of injury 3%-5% in the first year 12 times as great as for the population

Severe head trauma, cortical injury, neurologi deficit and - dura intact ; 7% -39%

- dura penetration ; 20%-57%

Early PTS

Incidence 2%-7% Unselected patients with head injury ~ 2% Consecutive admissions ~3%-6% Young children under 5 years ~7%-9% Severe head injury ~ 30% Mild head injury ~ 1-2 % SDH and ICH ~1/3 EDH, depressed skull fracture and prolong amnesia ~10%

Late PTS
Incidence 1.6% - 5% 25% of early seizure or ICH developed to late seizures Mild head injury ~ 1-2% Cranial missile wound ~1/3-1/2

Timing of Early PTS

1/3 within first hour 1/3 between 1-24 hours 1/3 between 1-7 days after injury

Timing of Late PTS 18% in first moth 57% in first year

Factors Associated with early post-traumatic seizures*

Incidence of Early Post-traumatic Seizures (per Cent)
Depressed skull fracture Subdural hematoma Intracerebral head injury Penetrating head injury Glasgow Coma Scale score less than or equal to 10 Epidural hematoma Cortical contusion Immediate seizures Linear fracture23 Post- traumatic amnesia greater than 24 hr23 No or brief unconsciousness23 No or brief unconsciousness, age younger than 5 yr23 27 24 23 20 20

17 16 28+ 6 12 6 17

Factors Associated with late post-traumatic seizures*

Incidence of Late Post-traumatic Seizures (per Cent) Penetrating missile wound44 Early seizures Intracerebral hematoma Subdural hematoma Glasgow Coma Scale score less than or equal to 10 Depressed skull fracture Cortical contusion Epidural hematoma Linear fracture26 Mild concussion23 53 47 40 33 32
31 28 26 5 <1

Seizures type of Early PTS

60%-80% focal seizure (more common in children or missile injury)

20%-40% generalized tonic clonic seizures

10% of adult and 20% of children younger than 5 years with early seizures developed status epilepticus

Seizures type of late PTS

60%-70% are generalized seizures, with or without focal onset 30%-40% are simple or complex partial seizures

Prevention and Prophylaxis

Ideally ; prophylaxis should aim at reducing the chance of developing PTE with drug treatment Aims ; ADEs prevention of early seizures after severe head trauma , to avoid complication

Prevention and Prophylaxis

Clinical observation (1970-1979)

Young et al, Wohn and Wyler concluded that antiepileptic drug prevented the development of PTS
Risk and Caveness no difference in early seizures occurrence between AEDs-treated and untreated patients

Prospective double blind with placebo control

Penry and colleagues (1979)

;serizures occurrence in the treated group 21% versus 13% in control Young et al (1983) ; 179 cases, 85 were treated (18 mo) 74 were control Seizures occurred 12.9% of treated and in 10.8% of the control patients

Temkin et al
At first year, no difference in incidence of PTS between the treatment and control groups By 2 years, PTS occurred in 27.5% of phenytoin treated patients and in 21.1% of control patients Observe that phenytoin was effective in preventing seizures during immediatedly after injury (1 or 2 weeks)

The New England Journal of Medicine (1990) (Temkin)

Randomized, double blind study for prevention of PTE 404 patients, treatment patients 208, control 196
Day 1- day 7 Day 8 end of Year 1 At the end of Year 2 Treatment 3.6% 21.5% 27.5% Placebo 14.2% 17.5 21.1%

Phenytoin exerts beneficial effect by reducing seizures only during the first week

walker and Erculei ; 50% have PTE would be in complete remission by 15 years after injury Remission of epilepsy is safer term than cessation 2 years without seizure is a reasonable definition of remission Clinicians recommend discontinuation of AEDs in adults after 2 years without epilepsy Intractable epilepsy ; should evaluation the patient for resective surgery

Conclusion
Routinely

prophylactic treatment with AEDs, IV loading dose as soon as possible after injury
Should

not routinely be used beyond the first

7 days Use AEDs in late PTE when ; early PTE or have seizures after 7 days Stop AEDs after 2 years without seizures