Post-traumatic seizure

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Post-traumatic seizures (PTS) are seizures that result from traumatic brain injury (TBI), brain damage caused by physical trauma. PTS may be a risk factor for post-traumatic epilepsy (PTE), but a person having a seizure or seizures due to traumatic brain injury does not necessarily have PTE, which is a form of epilepsy, a chronic condition in which seizures occur repeatedly. However, "PTS" and "PTE" may be used interchangeably in medical literature. [1]

Contents

Seizures are usually an indication of a more severe TBI. [1] Seizures that occur shortly after a person sustains a brain injury may further damage the already vulnerable brain. [2] They may reduce the amount of oxygen available to the brain, [3] cause excitatory neurotransmitters to be released in excess, increase the brain's metabolic need, and raise the pressure within the intracranial space, further contributing to damage. [2] Thus, people who sustain severe head trauma are given anticonvulsant medications as a precaution against seizures. [3]

Around 5–7% of people hospitalized with TBI have at least one seizure. [4] PTS are more likely to occur in more severe injuries, and certain types of injuries increase the risk further. The risk that a person will develop PTS becomes progressively lower as time passes after the injury. However, TBI survivors may still be at risk over 15 years after the injury. [5] Children and older adults are at a higher risk for PTS.

Classification

In the mid-1970s, PTS was first classified by Bryan Jennett into early and late seizures, those occurring within the first week of injury and those occurring after a week, respectively. [6] Though the seven-day cutoff for early seizures is used widely, it is arbitrary; seizures occurring after the first week but within the first month of injury may share characteristics with early seizures. [7] Some studies use a 30‑day cutoff for early seizures instead. [8] Later it became accepted to further divide seizures into immediate PTS, seizures occurring within 24 hours of injury; early PTS, with seizures between a day and a week after trauma; and late PTS, seizures more than one week after trauma. [9] Some consider late PTS to be synonymous with post-traumatic epilepsy. [10]

Early PTS occur at least once in about 4 or 5% of people hospitalized with TBI, and late PTS occur at some point in 5% of them. [9] Of the seizures that occur within the first week of trauma, about half occur within the first 24 hours. [11] In children, early seizures are more likely to occur within an hour and a day of injury than in adults. [12] Of the seizures that occur within the first four weeks of head trauma, about 10% occur after the first week. [5] Late seizures occur at the highest rate in the first few weeks after injury. [7] About 40% of late seizures start within six months of injury, and 50% start within a year. [11]

Especially in children and people with severe TBI, the life-threatening condition of persistent seizure called status epilepticus is a risk in early seizures; 10 to 20% of PTS develop into the condition. [11] In one study, 22% of children under 5 years old developed status seizures, while 11% of the whole TBI population studied did. [12] Status seizures early after a TBI may heighten the chances that a person will develop unprovoked seizures later. [11]

Pathophysiology

It is not completely understood what physiological mechanisms cause seizures after injury, but early seizures are thought to have different underlying processes than late ones. [13] Immediate and early seizures are thought to be a direct reaction to the injury, while late seizures are believed to result from damage to the cerebral cortex by mechanisms such as excitotoxicity and iron from blood. [2] Immediate seizures occurring within two seconds of injury probably occur because the force from the injury stimulates brain tissue that has a low threshold for seizures when stimulated. [14] Early PTS are considered to be provoked seizure, because they result from the direct effects of the head trauma and are thus not considered to be actual epilepsy, while late seizures are thought to indicate permanent changes in the brain's structure and to imply epilepsy. [11] Early seizures can be caused by factors such as cerebral edema, intracranial hemorrhage, cerebral contusion or laceration. [14] Factors that may result in seizures that occur within two weeks of an insult include the presence of blood within the brain; alterations in the blood brain barrier; excessive release of excitatory neurotransmitters such as glutamate; damage to tissues caused by free radicals; and changes in the way cells produce energy. [13] Late seizures are thought to be the result of epileptogenesis, in which neural networks are restructured in a way that increases the likelihood that they will become excited, leading to seizures. [13]

Diagnosis

Medical personnel aim to determine whether a seizure is caused by a change in the patient's biochemistry, such as hyponatremia. [2] Neurological examinations and tests to measure levels of serum electrolytes are performed. [2]

Not all seizures that occur after trauma are PTS; they may be due to a seizure disorder that already existed, which may even have caused the trauma. [15] In addition, post-traumatic seizures are not to be confused with concussive convulsions, which may immediately follow a concussion but which are not actually seizures and are not a predictive factor for epilepsy. [16]

Neuroimaging is used to guide treatment. Often, MRI is performed in any patient with PTS, but the less sensitive but more easily accessed CT scan may also be used. [17]

Prevention

Shortly after TBI, people are given anticonvulsant medication, because seizures that occur early after trauma can increase brain damage through hypoxia, [3] excessive release of excitatory neurotransmitters, increased metabolic demands, and increased pressure within the intracranial space. [2] Medications used to prevent seizures include valproate, phenytoin, and phenobarbital. [18] It is recommended that treatment with anti-seizure medication be initiated as soon as possible after TBI. [8] Prevention of early seizures differs from that of late seizures, because the aim of the former is to prevent damage caused by the seizures, whereas the aim of the latter is to prevent epileptogenesis. [3] Strong evidence from clinical trials suggests that antiepileptic drugs given within a day of injury prevent seizures within the first week of injury, but not after. [4] For example, a 2003 review of medical literature found phenytoin to be preventative of early, but probably not late PTS. [7] In children, anticonvulsants may be ineffective for both early and late seizures. [4] For unknown reasons, prophylactic use of antiepileptic drugs over a long period is associated with an increased risk for seizures. [1] For these reasons, antiepileptic drugs are widely recommended for a short time after head trauma to prevent immediate and early, but not late, seizures. [1] [19] No treatment is widely accepted to prevent the development of epilepsy. [3] However, medications may be given to repress more seizures if late seizures do occur. [18]

Treatment

Seizures that result from TBI are often difficult to treat. [13] Antiepileptic drugs that may be given intravenously shortly after injury include phenytoin, sodium valproate, carbamazepine, and phenobarbital. [2] Antiepileptic drugs do not prevent all seizures in all people, [5] but phenytoin and sodium valproate usually stop seizures that are in progress. [2]

Prognosis

PTS is associated with a generally good prognosis. [14] It is unknown exactly how long after a TBI a person is at higher risk for seizures than the rest of the population, but estimates have suggested lengths of 10 to over 15 years. [5] For most people with TBI, seizures do not occur after three months, and only 20–25% of people with TBI have PTS more than two years after the injury. [9] However, moderate and severe TBI still confer a high risk for PTS for up to five years after the injury. [4]

Studies have reported that 25–40% of PTS patients go into remission; later studies conducted after the development of more effective seizure medications reported higher overall remission rates. [5] In one quarter of people with seizures from a head trauma, medication controls them well. [1] However, a subset of patients have seizures despite aggressive antiepileptic drug therapy. [5] The likelihood that PTS will go into remission is lower for people who have frequent seizures in the first year after injury. [5]

Risk of developing PTE

It is not known whether PTS increase the likelihood of developing PTE. [13] Early PTS, while not necessarily epileptic in nature, are associated with a higher risk of PTE. [20] However, PTS do not indicate that development of epilepsy is certain to occur, [21] and it is difficult to isolate PTS from severity of injury as a factor in PTE development. [13] About 3% of patients with no early seizures develop late PTE; this number is 25% in those who do have early PTS, and the distinction is greater if other risk factors for developing PTE are excluded. [21] Seizures that occur immediately after an insult are commonly believed not to confer an increased risk of recurring seizures, but evidence from at least one study has suggested that both immediate and early seizures may be risk factors for late seizures. [5] Early seizures may be less of a predictor for PTE in children; while as many as a third of adults with early seizures develop PTE, the portion of children with early PTS who have late seizures is less than one fifth in children and may be as low as one tenth. [12] The incidence of late seizures is about half that in adults with comparable injuries. [12]

Epidemiology

The relative risk of PTS increases with the severity of injury. Pts bar graph by severity.svg
The relative risk of PTS increases with the severity of injury.
As age increases, risk of early and late seizures decreases. Pts bar graph by age.svg
As age increases, risk of early and late seizures decreases.

Research has found that the incidence of PTS varies widely based on the population studied; it may be as low as 4.4% or as high as 53%. [5] Of all TBI patients who are hospitalized, 5 to 7% have PTS. [4] PTS occur in about 3.1% of traumatic brain injuries, but the severity of injury affects the likelihood of occurrence. [9]

The most important factor in whether a person will develop early and late seizures is the extent of the damage to the brain. [2] More severe brain injury also confers a risk for developing PTS for a longer time after the event. [4] One study found that the probability that seizures will occur within 5 years of injury is in 0.5% of mild traumatic brain injuries (defined as no skull fracture and less than 30 minutes of post-traumatic amnesia, abbreviated PTA, or loss of consciousness, abbreviated LOC); 1.2% of moderate injuries (skull fracture or PTA or LOC lasting between 30 minutes and 24 hours); and 10.0% of severe injuries (cerebral contusion, intracranial hematoma, or LOC or PTA for over 24 hours). [23] Another study found that the risk of seizures 5 years after TBI is 1.5% in mild (defined as PTA or LOC for less than 30 minutes), 2.9% in moderate (LOC lasting between 30 minutes and 1 day), and 17.2% in severe TBI (cerebral contusion, subdural hematoma, or LOC for over a day; image at right). [2] [11]

Immediate seizures have an incidence of 1 to 4%, that of early seizures is 4 to 25%, and that of late seizures is 9 to 42%. [2]

Age influences the risk for PTS. As age increases, risk of early and late seizures decreases; one study found that early PTS occurred in 30.8% of children age 7 or under, 20% of children between ages 8 and 16, and 8.4% of people who were over 16 at the time they were injured (graph at right). [5] [22] Early seizures occur up to twice as frequently in brain injured children as they do in their adult counterparts. [5] In one study, children under five with trivial brain injuries (those with no LOC, no PTA, no depressed skull fracture, and no hemorrhage) had an early seizure 17% of the time, while people over age 5 did so only 2% of the time. [5] Children under age five also have seizures within one hour of injury more often than adults do. [11] One study found the incidence of early seizures to be highest among infants younger than one year and particularly high among those who sustained perinatal injury. [14] However, adults are at higher risk than children are for late seizures. [24] People over age 65 are also at greater risk for developing PTS after an injury, with a PTS risk that is 2.5 times higher than that of their younger counterparts. [25]

Risk factors

The chances that a person will develop PTS are influenced by factors involving the injury and the person. The largest risks for PTS are having an altered level of consciousness for a protracted time after the injury, severe injuries with focal lesions, and fractures. [8] The single largest risk for PTS is penetrating head trauma, which carries a 35 to 50% risk of seizures within 15 years. [2] If a fragment of metal remains within the skull after injury, the risk of both early and late PTS may be increased. [5] Head trauma survivors who abused alcohol before the injury are also at higher risk for developing seizures. [4]

Occurrence of seizures varies widely even among people with similar injuries. [5] It is not known whether genetics play a role in PTS risk. [11] Studies have had conflicting results with regard to the question of whether people with PTS are more likely to have family members with seizures, which would suggest a genetic role in PTS. [11] Most studies have found that epilepsy in family members does not significantly increase the risk of PTS. [5] People with the ApoE-ε4 allele may also be at higher risk for late PTS. [1]

Risks for late PTS include hydrocephalus, reduced blood flow to the temporal lobes of the brain, [1] brain contusions, subdural hematomas, [5] a torn dura mater, and focal neurological deficits. [9] PTA that lasts for longer than 24 hours after the injury is a risk factor for both early and late PTS. [1] Up to 86% of people who have one late post-traumatic seizure have another within two years. [5]

See also

Related Research Articles

<span class="mw-page-title-main">Epilepsy</span> Group of neurological disorders causing seizures

Epilepsy is a group of non-communicable neurological disorders characterized by recurrent epileptic seizures. An epileptic seizure is the clinical manifestation of an abnormal, excessive, purposeless and synchronized electrical discharge in the brain cells called neurons. The occurrence of two or more unprovoked seizures defines epilepsy. The occurrence of just one seizure may warrant the definition in a more clinical usage where recurrence may be able to be prejudged. Epileptic seizures can vary from brief and nearly undetectable periods to long periods of vigorous shaking due to abnormal electrical activity in the brain. These episodes can result in physical injuries, either directly such as broken bones or through causing accidents. In epilepsy, seizures tend to recur and may have no immediate underlying cause. Isolated seizures that are provoked by a specific cause such as poisoning are not deemed to represent epilepsy. People with epilepsy may be treated differently in various areas of the world and experience varying degrees of social stigma due to the alarming nature of their symptoms.

<span class="mw-page-title-main">Seizure</span> Period of symptoms due to excessive or synchronous neuronal brain activity

An epileptic seizure, informally known as a seizure, is a period of symptoms due to abnormally excessive or synchronous neuronal activity in the brain. Outward effects vary from uncontrolled shaking movements involving much of the body with loss of consciousness, to shaking movements involving only part of the body with variable levels of consciousness, to a subtle momentary loss of awareness. Most of the time these episodes last less than two minutes and it takes some time to return to normal. Loss of bladder control may occur.

<span class="mw-page-title-main">Head injury</span> Serious trauma to the cranium

A head injury is any injury that results in trauma to the skull or brain. The terms traumatic brain injury and head injury are often used interchangeably in the medical literature. Because head injuries cover such a broad scope of injuries, there are many causes—including accidents, falls, physical assault, or traffic accidents—that can cause head injuries.

<span class="mw-page-title-main">Brain damage</span> Destruction or degeneration of brain cells

Neurotrauma, brain damage or brain injury (BI) is the destruction or degeneration of brain cells. Brain injuries occur due to a wide range of internal and external factors. In general, brain damage refers to significant, undiscriminating trauma-induced damage.

<span class="mw-page-title-main">Cerebral edema</span> Excess accumulation of fluid (edema) in the intracellular or extracellular spaces of the brain

Cerebral edema is excess accumulation of fluid (edema) in the intracellular or extracellular spaces of the brain. This typically causes impaired nerve function, increased pressure within the skull, and can eventually lead to direct compression of brain tissue and blood vessels. Symptoms vary based on the location and extent of edema and generally include headaches, nausea, vomiting, seizures, drowsiness, visual disturbances, dizziness, and in severe cases, death.

<span class="mw-page-title-main">Concussion</span> Type of traumatic brain injury

A concussion, also known as a mild traumatic brain injury (mTBI), is a head injury that temporarily affects brain functioning. Symptoms may include loss of consciousness; memory loss; headaches; difficulty with thinking, concentration, or balance; nausea; blurred vision; dizziness; sleep disturbances, and mood changes. Any of these symptoms may begin immediately, or appear days after the injury. Concussion should be suspected if a person indirectly or directly hits their head and experiences any of the symptoms of concussion. Symptoms of a concussion may be delayed by 1–2 days after the accident. It is not unusual for symptoms to last 2 weeks in adults and 4 weeks in children. Fewer than 10% of sports-related concussions among children are associated with loss of consciousness.

<span class="mw-page-title-main">Traumatic brain injury</span> Injury of the brain from an external source

A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. TBI can be classified based on severity ranging from mild traumatic brain injury (mTBI/concussion) to severe traumatic brain injury. TBI can also be characterized based on mechanism or other features. Head injury is a broader category that may involve damage to other structures such as the scalp and skull. TBI can result in physical, cognitive, social, emotional and behavioral symptoms, and outcomes can range from complete recovery to permanent disability or death.

<span class="mw-page-title-main">Craniotomy</span> Surgical operation on skull

A craniotomy is a surgical operation in which a bone flap is temporarily removed from the skull to access the brain. Craniotomies are often critical operations, performed on patients who are suffering from brain lesions, such as tumors, blood clots, removal of foreign bodies such as bullets, or traumatic brain injury (TBI), and can also allow doctors to surgically implant devices, such as deep brain stimulators for the treatment of Parkinson's disease, epilepsy, and cerebellar tremor. The procedure is also used in epilepsy surgery to remove the parts of the brain that are causing epilepsy.

In emergency medicine, a lucid interval is a temporary improvement in a patient's condition after a traumatic brain injury, after which the condition deteriorates. A lucid interval is especially indicative of an epidural hematoma. An estimated 20 to 50% of patients with epidural hematoma experience such a lucid interval.

<span class="mw-page-title-main">Temporal lobe epilepsy</span> Chronic focal seizure disorder

In the field of neurology, temporal lobe epilepsy is an enduring brain disorder that causes unprovoked seizures from the temporal lobe. Temporal lobe epilepsy is the most common type of focal onset epilepsy among adults. Seizure symptoms and behavior distinguish seizures arising from the medial temporal lobe from seizures arising from the lateral (neocortical) temporal lobe. Memory and psychiatric comorbidities may occur. Diagnosis relies on electroencephalographic (EEG) and neuroimaging studies. Anticonvulsant medications, epilepsy surgery and dietary treatments may improve seizure control.

Post-concussion syndrome (PCS), also known as persisting symptoms after concussion, is a set of symptoms that may continue for weeks, months, years after a concussion. PCS is medically classified as a mild traumatic brain injury (TBI). About 35% of people with concussion experience persistent or prolonged symptoms 3 to 6 months after injury. Prolonged concussion is defined as having concussion symptoms for over four weeks following the first accident in youth and for weeks or months in adults.

Sudden unexpected death in epilepsy (SUDEP) is a fatal complication of epilepsy. It is defined as the sudden and unexpected, non-traumatic and non-drowning death of a person with epilepsy, without a toxicological or anatomical cause of death detected during the post-mortem examination.

<span class="mw-page-title-main">Chronic traumatic encephalopathy</span> Neurodegenerative disease caused by head injury

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease linked to repeated trauma to the head. The encephalopathy symptoms can include behavioral problems, mood problems, and problems with thinking. The disease often gets worse over time and can result in dementia.

Post-traumatic epilepsy (PTE) is a form of acquired epilepsy that results from brain damage caused by physical trauma to the brain. A person with PTE experiences repeated post-traumatic seizures more than a week after the initial injury. PTE is estimated to constitute 5% of all cases of epilepsy and over 20% of cases of acquired epilepsy.

Post-traumatic amnesia (PTA) is a state of confusion that occurs immediately following a traumatic brain injury (TBI) in which the injured person is disoriented and unable to remember events that occur after the injury. The person may be unable to state their name, where they are, and what time it is. When continuous memory returns, PTA is considered to have resolved. While PTA lasts, new events cannot be stored in the memory. About a third of patients with mild head injury are reported to have "islands of memory", in which the patient can recall only some events. During PTA, the patient's consciousness is "clouded". Because PTA involves confusion in addition to the memory loss typical of amnesia, the term "post-traumatic confusional state" has been proposed as an alternative.

Primary and secondary brain injury are ways to classify the injury processes that occur in brain injury. In traumatic brain injury (TBI), primary brain injury occurs during the initial insult, and results from displacement of the physical structures of the brain. Secondary brain injury occurs gradually and may involve an array of cellular processes. Secondary injury, which is not caused by mechanical damage, can result from the primary injury or be independent of it. The fact that people sometimes deteriorate after brain injury was originally taken to mean that secondary injury was occurring. It is not well understood how much of a contribution primary and secondary injuries respectively have to the clinical manifestations of TBI.

Traumatic brain injury can cause a variety of complications, health effects that are not TBI themselves but that result from it. The risk of complications increases with the severity of the trauma; however even mild traumatic brain injury can result in disabilities that interfere with social interactions, employment, and everyday living. TBI can cause a variety of problems including physical, cognitive, emotional, and behavioral complications.

Generally, seizures are observed in patients who do not have epilepsy. There are many causes of seizures. Organ failure, medication and medication withdrawal, cancer, imbalance of electrolytes, hypertensive encephalopathy, may be some of its potential causes. The factors that lead to a seizure are often complex and it may not be possible to determine what causes a particular seizure, what causes it to happen at a particular time, or how often seizures occur.

A sports-related traumatic brain injury is a serious accident which may lead to significant morbidity or mortality. Traumatic brain injury (TBI) in sports are usually a result of physical contact with another person or stationary object, These sports may include boxing, gridiron football, field/ice hockey, lacrosse, martial arts, rugby, soccer, wrestling, auto racing, cycling, equestrian, rollerblading, skateboarding, skiing or snowboarding.

Ramon Diaz-Arrastia is an American neurologist and clinical investigator. He is the John McCrae Dickson, MD Presidential professor of Neurology at the University of Pennsylvania Perelman School of Medicine in Philadelphia, Director of Clinical Traumatic Brain Injury Research, and Attending Neurologist at the Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center.

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