1、Posttraumatic Seizure(PTS)Risk and Management in TBI:ObjectivesGuidelines for PTS prophylaxis:AANS,AAPMRPredict PTS risk based on clinical presentationAnalyze treatment strategies for individuals with late PTS from case studyPosttraumatic Seizure(PTS)definitionTemporary brain dysfunction with excess
2、ive,hypersynchronous discharge of cortical neurons Immediate:first 24 hours post injury Early PTS:first 7 days Late PTS:after one week EpilepsyRecurrent unprovoked seizures TBI accounts for 5-20%symptomatic epilepsy in general population Early PTS-3-15%adults,10-15%children;17-33%develop late PTS,ad
3、ults children Late PTS-86%recurrent seizures in 2 yrs(Haltiner et al,2019)Consumer Feedback early 1990s:Anticonvulsants(AED)No Standard of care:AEDs continued indefinitely MDs reluctant to discontinue medications,especially prescribed by another MD Memory problems and compliance Drug side effects:at
4、axia,rashes,periodontal care,hair growth or loss,slowed thinking Cost of medications,laboratory testsAANS(2019,2000)and AAPM&R(2019)Practice Parameters Recognize effects of AEDs on recovery,compliance Lack of efficacy in prevention of late PTS Option:Phenytoin,carbamazepine may prevent early PTS in
5、high risk TBI;early PTS treatment does not prevent late PTS or improve outcome Standard:Prophylactic anticonvulsants not recommended for prevention of late PTSTraditional Risk Factors for late PTS Penetrating shrapnel injuries,military:53%over 15 years(Salazar,1985)Coma 3 weeks:25%(Guidice,1987)Earl
6、y PTS-late PTS:17-33%,age related in some studies Intracranial hematoma:Epidural,22%;subdural or intracerebral,45%(Jennett,1975)Multi-center study rationale What is natural history late PTS with new guidelines?CT scan findings not incorporated into risk factor profile in previous studies Civilian gu
7、nshot wounds may be different from military shrapnel wounds-seizure risk Follow-up mechanisms already in place through TBI Model Systems grants:sufficient numbersHypotheses:multi-center,prospective study late PTS by 2 years 1st year incidence 2nd year GCS injury severity will predict late PTS Intrac
8、ranial lesions by CT scan predict late PTS Dural penetration predict late PTSProspective enrollment of severe TBI Trauma centers:Denver,Richmond,Detroit,San Jose 16 yo,not pregnant,no previous seizure,stroke,tumor,intracranial surgery;AEDs 1 mo post TBI CT lesions during first week post TBI SAH or i
9、ntraventricular hemorrhage cerebral contusion epidural or subdural hematoma depressed skull fracture with dural penetration OR Best GCS in first 24 hours 80%Confirmed events categorized by neurologist generalized or focal-generalized seizure focal seizure Statistics:survival analysis,relative risk c
10、alculationsTime course and quality of late posttraumatic seizures 647 enrolled over 4 years 14%late PTS by 2 years 40%occurred 8-30 days 63%by 6 months 80%by 12 months 93%by 18 months 79%generalized;21%focalEarly PTS(7days post injury)and late PTS 21/647(3%)had early seizures Next seizure occurred 6
11、 months if early PTSInitial GCS and late PTS GCS 3-8:17%relative risk GCS 9-12:24%relative risk GCS 13-15:8%relative riskSeverity of injury as measured by GCS did not correlate with late PTSGCS not particularly helpful in predicting seizure riskMidline shift and cisternal compression on CT scan and
12、late PTS Cisterns open,1 mm shift:10%Cisterns open,1-5 mm shift:15%Cisterns compressed,5 mm shift:26%Degree of cerebral compression is associated with late PTS,especially 5 mm midline shiftCortical Contusions:Relative risk of late PTS No contusion:6%Single contusion:8%Bilateral or multiple contusion
13、s:25%bifrontal:26%bitemporal:31%biparietal:66%Bilateral contusions amongst highest risk factors for late PTSSubcortical contusions and relative risk for late PTS No subcortical contusion:13%Single subcortical contusion:16%Multiple subcortical contusions:33%High association of multiple subcortical co
14、ntusions and late PTS:probably marker for severe TBI.Penetrating Injuries and late PTS No penetrating bone,metal fragments:14%Bone fragments only:0%Bone and metal fragments:63%Metal fragments(bullets)have a very high association with late PTS and are comparable to shrapnel injuries.Bone fragments al
15、one have minimal increased risk.Mass lesions and relative risk of late PTS Epidural hematoma(EDH)no EDH:14%EDH,no evacuation:8%EDH with evacuation:19%Subdural hematoma(SDH)no SDH:10%SDH,no evacuation:15%SDH with evacuation:28%Neurosurgical procedures and relative risk of late PTS 1 evacuation of int
16、racerebral hematoma:75%1 operation:37%;1 operation:15%;none:11%Ventriculostomy:25%;no ventriculostomy:13%More severe injuries require more neurosurgical procedures;those individuals have higher risk of late PTSLength of phenytoin prophylaxis and relative risk of late PTSDays DPH%Relative risk None7%
17、1-7 days12%8-14 days17%15-30 days30%*p=.0002Probably a marker for more severe injuryStudy Limitations Dural penetration“n”too small(26/647)Prolonged or late anticonvulsant use:sicker patients had to be dropped Self report of symptoms:bias to seizures that generalize as these are more recognizable Co
18、ncomitant factors:midline shift is often a criteria for surgery,so which is the predominant risk factor?Conclusions AANS and AAPMR guidelines are supported Most PTS occur in 18 mos post TBI GCS severity insufficient to predict PTS riskConclusions Very high risk groups:early PTS,multiple contusions,m
19、idline shift 5mm,subdural hematoma surgery,multiple operations,bone and metal fragments Is there a role for prophylaxis in very high risk groups?Double blind randomized study,more institutions Quality of life,RTW/school,independent living in individuals with PTS v none:needs studyRT case study slide
20、 120 yo man with GSW to left temporal occipital areasR cavernous carotid fistula-balloon occlusionLate PTS when developed severe hydrocephalusVentriculoperitoneal shunt 10 weeks post injuryAcute rehab 13 weeks post injury,Rancho 3-4valproate for seizure and pantoprazole for GI protection;cuffed trac
21、heostomyCommunicates with eye blinks,finger movementsCr N 2,3,6,7,9,10,12 injuriesRUE some selective movement;tremor and synergy in LUE,bilateral LEWhat is his risk factor profile?Continue to treat?RT case study slide 2With consent from brother valproate is tapered to decrease tremor;everyone watchi
22、ng for seizuresYou deflate his trach and within 2 days change to cuffless Foley to condom catheter,continuous to bolus feedingCogwheel rigidity and tremor with movement,no seizuresHow do you treat his cogwheel rigidity and tremor?RT case study slide 3Sinemet started using ADL and wheelchair mobility
23、 as performance parameters4 1/2 months post injury,30 second LOC,LE shaking and difficulty breathing.Resumed previous level of functioning within hours What is this episode?What diagnostic interventions are appropriate?RT case study slide 4Complex partial seizure with respiratory distress No evidenc
24、e of infection in lungs,urine Electrolytes(Na,Ca,Mg,CO2,BUN/Cr)normal CT scan showed continued improvement in hydrocephalus,subdural fluid collectionsUnprovoked seizure,associated with very high incidence of recurrent episodes What medication would cause the least toxicity?RT case study slide 5 Lamo
25、trigine picked because low sedation potential,low incidence of motor side effects Gradual build-up of dose OK,given rapid recovery from this seizure event Other medication considerations Valproate,phenytoin,carbamazepine:motoric side effects levetiracetam:renal clearance,not sedating oxcarbazepine:l
26、ess motor toxicity than carbamazepineDK case study slide 126 yo LH female,motorcycle crash while helmetedEMS GCS 6,eyes deviated to left,bloody vomitus in mouth,tonic-clonic movements in extremitiesCT scan:R maxillary sinus fracture,no contusionsSocial:street drug arrests;sober,working 2 years What
27、is this episode?How should she be treated?DK case study slide 2Immediate PTS Intubated in ER;ICP monitor showed 38 mm Hg ICP controlled with ventilation,mannitol Phenytoin started IV Follow-up CT scan:bifrontal contusions,L subdural hygroma Tracheostomy performed after failed weaning Agitation manag
28、ed with lorazepamHow long should she be treated with AEDs?SDK case study slide 33 weeks post injury,admission to acute rehabilitation tracheostomy,NG tube with continuous feedings,non fluent aphasia,L hemiparesis,L VF defect,Rancho 3-4,max assistance mobility and ADLs.Meds:phenytoin,prn lorazepam,pe
29、pcid How would you manage her rehabilitation and her medicationsDK case study slide 4Regulate schedule for mobility,ADL,bolus feeding,communication strategies,net bed,wean trachDC phenytoin,pepcid.Taper benzodiazepines to improve level of alertness.No indication.PTA resolves 6 weeks;safety awareness
30、 improves7 weeks post TBI,episode of unresponsiveness,head and eye deviation to left for 80%Driving not immediate issue:VF deficit Support reasonable choice by patient,familyShe decides to take a chance without medicationConsiderations of antiepileptic drug choice Compliance:once/day vs.multiple dos
31、es phenytoin,phenobarbital once/day all others are 2-3 times/day Desired side effects:mood stabilization,neuropathic pain Undesired side effects:sedation,interactions,cognitive slowing,weight gain,blood monitoring,hair and gingival growthBibliographyBrain Injury Special Interest Group of the America
32、n Academy of Physical Medicine and Rehabilitation,Practice parameter:antiepileptic drug treatment of posttraumatic seizures.Arch Phys Med Rehabil 2019;79;594-597Brain Trauma Foundation,American Association of Neurological Surgeons,The role of antiseizure prophylaxis following head injury in Guidelin
33、es for the management of severe traumatic brain injury.ISBN 0-9703144-0-X:159-165Englander J,Bushnik T,Duong TT,Cifu DX,et al,Analyzing risk factors for late posttraumatic seizures:a prospective,multi-center investigation.Arch Phys Med Rehabil 2019;84:365-373Jennet B,Epilepsy after non-missile head
34、injuries,ed 2.Chicago:William Heinemann,1975Haltiner AM,Temkin NR,Dickmen SS,Risk of seizure recurrence after the first PTS.Arch Phys Med Rehabil 2019;78;835-840.Salazar AM et al,Epilepsy after penetrating head injury:1.Clinical correlates.Neurology 1985;35:1406-1414.Yablon S,Posttraumatic seizures.Arch Phys Med Rehabil 1993;74;983-1001谢谢
