Post-Traumatic Epilepsy Enrique Feoli MD North East Regional Epilepsy Group 2014

Videos https://www.youtube.com/watch?v=BfQ8OxErihk https://www.youtube.com/watch?v=eW9GRDe4v-Y http://www.youtube.com/watch?v=nZ8p90Bfqng&feature=player_detailpage

Scope of the issue: USA 1.7 million/Year* (adult and children) *leading cause of death and disability USA and other industrialized countries 3.2-5.3 mill. citizens /w lifelong disability 53K Die from TBI (Ann Average) 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 Early seizures (1 to 7 days) Immediate Sz Late seizures (epilepsy) ( 0 to 24 hs) (40% in the firs 6 months) Trauma 7 days

TBI: Civilian Background Motor vehicles/Falls (75%) Men “excel”: TBI: 2-2 ½ times vs. women Bimodal Young Old men

Criteria for TBI Loss of Awareness (consciousness) Sustained focal deficit Imaging abnormality (ICH, Contusion…)

Key Point: Severity of TBI Mild: GCS: 13-15 Moderate: GCS: 9-12 Severe: GCS: 8 or less; obtunded/coma

TBI and Seizures (6)

Risk of Post Traumatic Epilepsy Mild: 1.5% Moderate: 4.0% Severe: 28%

Risk Factors for PTE Severity of Head Injury! > 65 years of age Brain contusion Intra-cerebral hematoma Early Seizures (1st week post trauma)

Seizure Risk in Brain Injuries (6) Evaluation of Seizure Risk

PTE-How Long to Develop? Highest: first year. Decreases each year Mild TBI : Standardized incidence ratio: 1.5 in the first 5 years Mod TBI: SIR: 2.9, inc. Risk lasted 10yrs. 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 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 Severe TBI Acute Prophylaxis: Typically 7 Days (phenytoin) Does not modify course/prevent late seizures Acute and Chronic: once established Medications (greater than 22 available) Modify lifestyle Machines Surgery

Can PTE be Prevented Early seizures (1 to 7 days) Immediate Sz Late seizures (epilepsy) ( 0 to 24 hs) (40% in the firs 6 months) Trauma 7 days

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 Anti seizure medications Hypothermia Magnesium

Can PTE be Prevented Dilantin Carbamazepine Phenobarbital Early seizures (1 to 7 days) Immediate Sz Late Dilantin Carbamazepine Phenobarbital Levetiracetam Have all been proven to be effective in decreasing the frequency of early pot-traumatic seizures, however none have shown the decrease the incidence of PTE Trauma 7 days

Animals Effect of treatment on the epileptogenesis after TBI in experimental models Rimonabant sinngle dose6 wk Echegoyen et Minozac 6 h post-TBI two doses7 d Chrzaszcz et al. 48 Ketogenic diet Schwartzkroin et HypothermiaParasagittal FP30 min post-TBI for 4 h12 wk Atkins et al. 

Hypothermia No studies in human

Magnesium No studies in humans

Conclusions