Posttraumatic seizures อ. นพ. ธัญญา นรเศรษฐ์ ธาดา หน่วยประสาท ศัลยศาสตร์ ภาควิชาศัลยศาสตร์ โรงพยาบาลมหาราช นครเชียงใหม่

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 release : Unconscious

Incidence :  PTE related to severity of injury 3%-5% in the first year 12 times as great as for the population 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% Incidence 2%-7% Unselected patients with head injury ~ 2% Unselected patients with head injury ~ 2% Consecutive admissions ~3%-6% Consecutive admissions ~3%-6% Young children under 5 years ~7%-9% Young children under 5 years ~7%-9% Severe head injury ~ 30% Severe head injury ~ 30% Mild head injury ~ 1-2 % Mild head injury ~ 1-2 % SDH and ICH ~1/3 SDH and ICH ~1/3 EDH, depressed skull fracture and prolong amnesia ~10% EDH, depressed skull fracture and prolong amnesia ~10%

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

Timing of Early PTS 1/3 within first hour 1/3 within first hour 1/3 between 1-24 hours 1/3 between 1-24 hours 1/3 between 1-7 days after injury 1/3 between 1-7 days after injury Timing of Late PTS 18% in first moth 18% in first moth 57% in first year 57% in first year

Factors Associated with early post-traumatic seizures* Incidence of Early Incidence of Early Post-traumatic Seizures Post-traumatic Seizures (per Cent) (per Cent) Depressed skull fracture 27 Subdural hematoma 24 Intracerebral head injury 23 Penetrating head injury 20 Glasgow Coma Scale score less than or 20 equal to 10 equal to 10 Epidural hematoma 17 Cortical contusion 16 Immediate seizures 28+ Linear fracture 23 6 Post- traumatic amnesia greater than 24 hr No or brief unconsciousness 23 6 No or brief unconsciousness, age younger 17 than 5 yr 23 than 5 yr 23

Factors Associated with late post-traumatic seizures* Incidence of Late Incidence of Late Post-traumatic Seizures Post-traumatic Seizures (per Cent) (per Cent) Penetrating missile wound Early seizures 47 Intracerebral hematoma 40 Subdural hematoma 33 Glasgow Coma Scale score less than or 32 equal to 10 equal to 10 Depressed skull fracture 31 Cortical contusion 28 Epidural hematoma 26 Linear fracture 26 5 Mild concussion 23 <1

Seizures type of Early PTS 60%-80% focal seizure (more common in children or missile injury) 60%-80% focal seizure (more common in children or missile injury) 20%-40% generalized tonic – clonic seizures 20%-40% generalized tonic – clonic seizures 10% of adult and 20% of children younger than 5 years with early seizures developed status epilepticus 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 60%-70% are generalized seizures, with or without focal onset 30%-40% are simple or complex partial seizures 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 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 Aims ; ADEs prevention of early seizures after severe head trauma, to avoid complication

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

Prospective double – blind with placebo control Prospective double – blind with placebo control Penry and colleagues (1979) Penry and colleagues (1979) ;serizures occurrence in the treated group 21% versus 13% in control Young et al (1983) 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 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 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 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) 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 Randomized, double blind study for prevention of PTE 404 patients, treatment patients 208, control 196 Day 1- day 7 Treatment3.6%Placebo14.2% Day 8 – end of Year %17.5 At the end of Year %21.1% Phenytoin exerts beneficial effect by reducing seizures only during the first week 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