Post-Traumatic Epilepsy
Enrique Feoli MD
North East Regional Epilepsy Group
2014
Videos
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https://www.youtube.com/watch?v=BfQ8OxErihk
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https://www.youtube.com/watch?v=eW9GRDe4v-Y
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http://www.youtube.com/watch?v=nZ8p90Bfqng&fea
ture=player_detailpage
Scope of the issue: USA
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1.7 million/Year* (adult and children)
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*leading cause of death and disability USA and other industrialized countries
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3.2-5.3 mill. citizens /w lifelong disability
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53K Die from TBI (Ann Average)
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Firearms 35% 15-34y/o + > 75 y/o(8.5 and 10.5/100K)
MVA 31% 15-24 y/o
Falls 16.7 >75 y/o
Estimate annual cost of TBI ($60 billion US)
 http://www.cdc.gov/nchs/data
Terminology
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Early seizures (1 to 7 days)
Trauma
7 days
Immediate Sz
( 0 to 24 hs)
Late seizures (epilepsy)
(40% in the firs 6 months)
TBI: Civilian
Background
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Motor vehicles/Falls (75%)
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Men “excel”: TBI: 2-2 ½ times vs. women
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Bimodal
Young
 Old men
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Criteria for TBI
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Loss of Awareness (consciousness)
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Sustained focal deficit
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Imaging abnormality (ICH, Contusion…)
Key Point: Severity of TBI
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Mild: GCS: 13-15
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Moderate: GCS: 9-12
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Severe: GCS: 8 or less; obtunded/coma
TBI and Seizures
(6)
Risk of Post Traumatic Epilepsy
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Mild: 1.5%
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Moderate: 4.0%
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Severe: 28%
Risk Factors for PTE
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Severity of Head Injury!
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> 65 years of age
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Brain contusion
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Intra-cerebral hematoma
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Early Seizures (1st week post trauma)
Seizure Risk in Brain Injuries
(6)
Evaluation of Seizure Risk
PTE-How Long to Develop?
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Highest: first year.
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Decreases each year
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Mild TBI : Standardized incidence ratio: 1.5 in
the first 5 years
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Mod TBI: SIR: 2.9, inc. Risk lasted 10yrs.
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Severe TBI: SIR:17, inc risk lasting 20 yrs
TBI Symptoms
Epilepsy
Seizures, Complex Partial
Simple partial seizures
Secondary generalized
Psychogenic Non Epileptic events, about 30 % of
patient with TBI have PNES
TBI Symptoms
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posttraumatic stress disorder
anxiety disorders,
personality disorders,
aggressive disorders,
cognitive changes,
chronic pain,
sleep problems,
motor or sensory impairments, endocrine dysfunction,
gastrointestinal disturbances,
parkinsonism,
Humeral Fracture after generalized
status epilepticus
Aspiration Pneumonia after GTC
Seizure
Burns
PTE Treatment
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Severe TBI Acute Prophylaxis:
Typically 7 Days (phenytoin)
 Does not modify course/prevent late seizures
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Acute and Chronic: once established
Medications (greater than 22 available)
 Modify lifestyle
 Machines
 Surgery
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Can PTE be Prevented
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Early seizures (1 to 7 days)
Trauma
7 days
Immediate Sz
( 0 to 24 hs)
Late seizures (epilepsy)
(40% in the firs 6 months)
Mechanism of injury in TBI
(5)
Defining TBI and Seizure
“Shear” Injury
GSW
Doc: “I got a headache”….
Long Term: Encephalomalacia
Brain Trauma
Prevention Trials
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Anti seizure medications
Hypothermia
Magnesium
Can PTE be Prevented
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Early seizures (1 to 7 days)
Trauma
7 days
Immediate Sz
Dilantin
 Carbamazepine
 Phenobarbital
 Levetiracetam
Have all been proven to be
effective in decreasing the
frequency of early pottraumatic seizures, however
none have shown the
decrease the incidence of
PTE
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Late
Animals
Effect of treatment on the epileptogenesis after TBI in
experimental models
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Rimonabant sinngle dose6 wk Echegoyen et
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Minozac 6 h post-TBI two doses7 d Chrzaszcz et al. 48
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Ketogenic diet Schwartzkroin et
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HypothermiaParasagittal FP30 min post-TBI for 4 h12 wk
Atkins et al.
Hypothermia
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No studies in human
Magnesium
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No studies in humans
Conclusions