Post traumatic seizure

Definitions of post traumatic seizures:

(Brain Injury Special Interest Group 1998)
• Seizure: Discrete clinical event that reflects a temporary physiologic
dysfunction of the brain characterized by excessive & hypersynchronous
discharge of cortical neurons.

• Epilepsy: A condition characterized by recurrent unprovoked seizures.

• Post-Traumatic Seizure: An initial single or recurrent seizure episode not

attributable to another obvious cause after penetrating or non-penetrating
TBI. The term encompasses both single and recurrent events.

• Post-Traumatic Epilepsy: A disorder characterized by recurrent late seizure

episodes not attributable to another obvious cause in patients following
TBI. The term should be reserved for recurrent late PTS
PTS vs PTE
-Single or recurrent seizures during the first week after TBI (PTS) are
considered provoked, an acute complication from head injury
vs
recurrent seizures occurring 1 week after TBI are considered a
manifestation of PTE and if only a single seizure occurs it is known as
late PTS.
Definitions:
• Immediate Post-Traumatic Seizure: A seizure due to TBI occurring
within the first 24 hours of injury.

• Early Post-Traumatic Seizure: A seizure due to TBI occurring within

the first week of injury.

• Late Post-Traumatic Seizure: A seizure due to TBI occurring after the

first week of injury.
 Identification of ‘high risk’ patients
- What factors are predictive of an ABI patient at high risk of
seizures?
1. Patient characteristics: -increasing age
-premorbid alcohol use
- family history of seizure
2. Injury Characteristics: -bone/metal fragments
-depressed skull fracture,
-focal contusions/injury,
-focal neurological deficits
-dural penetration
-intracranial hemorrhage
-injurity severity:more severe injury.
3. Presence of early post-traumatic seizures (within 1st week of injury)-↑ risk of late
post-traumatic seizures
Natural history of post-traumatic seizure
• The risk of epilepsy is highest within the first 2 years following brain trauma
(55-67% of PTS patients will experience seizure within the first 12 months and 75-80% by the end
of the second year)

• As brain injury severity increases, the period of time for which a survivor is
at risk of developing post- traumatic seizures also increases. (Patients with
moderate to severe TBI or penetrating TBI remain at increased risk for more than 5 years post
TBI.)

• Seizure recurrence: Individuals who develop seizures after the first week
following TBI have an ↑ chance of experiencing seizure recurrence;
seizures occurring immediately following TBI do not ↑the risk of
recurrence. (epileptogenesis vs direct brain insult)
Complications of post-traumatic seizures
1. Deterioration in cognitive and behavioural functioning.
2. Deterioration in overall functional status.
3. Negative impact on neurological recovery.
4. Status epilepticus
5. Mortality
Seizure Prevention or Prophylaxis
What evidence is there to support the prophylactic use of anticonvulsants after ABI?

-Level 1 evidence that anticonvulsants given during the first 24 hours post-
ABI reduce the occurrence of early seizures (within the first week post-
injury).

-Level 1 evidence that anticonvulsants given shortly after the onset of injury,
do not reduce mortality or persistent vegetative state or the occurrence of
late seizures (> one week post-injury).

-Level 1 evidence that seizure prophylactic treatment with either phenytoin

or valproate results in similar incidences of early or late seizures and similar
mortality rates.
Seizure treatment
-In the TBI population, carbamazepine (partial seizures) and valproic
acid (generalized seizures) are often preferred to medications that
are more sedating or associated with cognitive impairment (such
as phenobarbital and phenytoin).

-Their superiority over phenytoin has been debated, but the

differences among these agents are probably minimal

(Brain Injury Special Interest Group of the AAPM&R, 1998).