Transcript Post Traumatic seizures

Posttraumatic
seizures
อ.นพ.ธัญญา นรเศรษฐ์ธาดา
หน่วยประสาทศัลยศาสตร์
ภาควิชาศัลยศาสตร์
โรงพยาบาลมหาราชนครเชียงใหม่
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
: Hypertension
: Metabolic changes
: Increased IC hypertension
: Excess neurotransmitter
: Unconscious
release
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
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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
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Timing of Early PTS
1/3 within first hour
 1/3 between 1-24 hours
 1/3 between 1-7 days after injury
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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
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60%-80% focal seizure (more common in
children or missile injury)

20%-40% generalized tonic – clonic
seizures
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10% of adult and 20% of children younger
than 5 years with early seizures developed
status epilepticus
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Seizures type of late PTS
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60%-70% are generalized seizures, with
or without focal onset
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30%-40% are simple or complex partial
seizures
Prevention and Prophylaxis
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Ideally ; prophylaxis should aim at
reducing the chance of developing PTE
with drug treatment
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Aims ; ADEs prevention of early seizures
after severe head trauma , to avoid
complication
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Prevention and Prophylaxis
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Clinical observation (1970-1979)
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Young et al, Wohn and Wyler concluded that
antiepileptic drug prevented the development
of PTS
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Risk and Caveness no difference in early
seizures occurrence between AEDs-treated
and untreated patients
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Prospective double – blind with placebo control
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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
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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)
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The New England Journal of
Medicine (1990) (Temkin)
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Randomized, double blind study for prevention of
PTE 404 patients, treatment patients 208, control
196
Treatment
3.6%
Placebo
14.2%
Day 8 – end of
Year 1
21.5%
17.5
At the end of
Year 2
27.5%
21.1%
Day 1- day 7
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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
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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