Post-Traumatic Post-Traumatic EpilepsyEpilepsy

Enrique Feoli MDEnrique Feoli MD

North East Regional Epilepsy North East Regional Epilepsy GroupGroup

20142014

VideosVideos https://www.youtube.com/watch?v=BfQ8OxEri

hk

https://www.youtube.com/watch?v=eW9GRDe4v-Y

http://www.youtube.com/watch?v=nZ8p90Bfqng&feature=player_detailpage

Scope of the issue: USAScope of the issue: USA

1.7 million/Year* (adult and children) 1.7 million/Year* (adult and children) *leading cause of death and disability USA and other industrialized countries*leading cause of death and disability USA and other industrialized countries

3.2-5.3 mill. citizens /w 3.2-5.3 mill. citizens /w lifelonglifelong disability disability

53K Die from TBI (Ann Average)53K Die from TBI (Ann Average) Firearms 35% 15-34y/o + > 75 y/o(8.5 and 10.5/100K)Firearms 35% 15-34y/o + > 75 y/o(8.5 and 10.5/100K) MVA 31% 15-24 y/oMVA 31% 15-24 y/o Falls 16.7 >75 y/oFalls 16.7 >75 y/o

Estimate annual cost of TBI ($60 billion US)Estimate annual cost of TBI ($60 billion US) http://www.cdc.gov/nchs/data

TerminologyTerminology Early seizures (1 to 7 days)Early seizures (1 to 7 days)

Immediate Sz Late seizures Immediate Sz Late seizures (epilepsy)(epilepsy)

( 0 to 24 hs) (40% in the firs 6 ( 0 to 24 hs) (40% in the firs 6 months)months)

Trauma

7 days

TBI: Civilian TBI: Civilian BackgroundBackground

Motor vehicles/Falls (75%)Motor vehicles/Falls (75%)

Men “excel”: TBI: 2-2 ½ times vs. Men “excel”: TBI: 2-2 ½ times vs. women women

Bimodal Bimodal Young Young Old menOld men

Criteria for TBICriteria for TBI

Loss of Awareness (consciousness)Loss of Awareness (consciousness)

Sustained focal deficitSustained focal deficit

Imaging abnormality (ICH, Imaging abnormality (ICH, Contusion…)Contusion…)

Key Point: Severity of Key Point: Severity of TBITBI

Mild: GCS: 13-15Mild: GCS: 13-15

Moderate: GCS: 9-12Moderate: GCS: 9-12

Severe: GCS: 8 or less; Severe: GCS: 8 or less; obtunded/comaobtunded/coma

(6)

TBI and SeizuresTBI and Seizures

Risk of Post Traumatic Risk of Post Traumatic EpilepsyEpilepsy

Mild: 1.5%Mild: 1.5%

Moderate: 4.0%Moderate: 4.0%

Severe: 28%Severe: 28%

Risk Factors for PTERisk Factors for PTE Severity of Head Injury!Severity of Head Injury!

> 65 years of age> 65 years of age

Brain contusionBrain contusion

Intra-cerebral hematomaIntra-cerebral hematoma

Early Seizures (1st week post Early Seizures (1st week post trauma) trauma)

(6) Evaluation of Seizure Risk

Seizure Risk in Brain Seizure Risk in Brain InjuriesInjuries

PTE-How Long to PTE-How Long to Develop?Develop?

Highest: first year. Highest: first year. Decreases each yearDecreases each year

Mild TBI : Standardized incidence ratio: Mild TBI : Standardized incidence ratio: 1.5 in the first 5 years1.5 in the first 5 years

Mod TBI: SIR: 2.9, inc. Risk lasted 10yrs.Mod TBI: SIR: 2.9, inc. Risk lasted 10yrs.

Severe TBI: SIR:17, inc risk lasting 20 yrsSevere TBI: SIR:17, inc risk lasting 20 yrs

TBI Symptoms TBI Symptoms

EpilepsyEpilepsy

Seizures, Complex PartialSeizures, Complex Partial

Simple partial seizuresSimple partial seizures

Secondary generalizedSecondary generalized

Psychogenic Non Epileptic events, Psychogenic Non Epileptic events, about 30 % of patient with TBI have about 30 % of patient with TBI have PNESPNES

TBI SymptomsTBI Symptoms

posttraumatic stress disorder posttraumatic stress disorder anxiety disorders, anxiety disorders, personality disorders, personality disorders, aggressive disorders, aggressive disorders, cognitive changes, cognitive changes, chronic pain, chronic pain, sleep problems, sleep problems, motor or sensory impairments, endocrine motor or sensory impairments, endocrine

dysfunction, gastrointestinal disturbances, dysfunction, gastrointestinal disturbances, parkinsonism,  parkinsonism, 

Humeral Fracture after Humeral Fracture after generalized status generalized status

epilepticusepilepticus

Aspiration Pneumonia after Aspiration Pneumonia after GTC SeizureGTC Seizure

BurnsBurns

PTE Treatment PTE Treatment

Severe TBI Acute Prophylaxis:Severe TBI Acute Prophylaxis: Typically 7 Days (phenytoin)Typically 7 Days (phenytoin) Does not modify course/prevent late Does not modify course/prevent late

seizuresseizures Acute and Chronic: once establishedAcute and Chronic: once established

Medications (greater than 22 available)Medications (greater than 22 available) Modify lifestyleModify lifestyle MachinesMachines SurgerySurgery

Can PTE be PreventedCan PTE be Prevented Early seizures (1 to 7 days)Early seizures (1 to 7 days)

Immediate Sz Late seizures Immediate Sz Late seizures (epilepsy)(epilepsy)

( 0 to 24 hs) (40% in the firs 6 ( 0 to 24 hs) (40% in the firs 6 months)months)

Trauma

7 days

(5) Defining TBI and Seizure

Mechanism of injury in Mechanism of injury in TBITBI

““Shear” InjuryShear” Injury

 

 

GSWGSW

Doc: “I got a Doc: “I got a headache”….headache”….

Long Term: Long Term: EncephalomalaciaEncephalomalacia

Brain TraumaBrain Trauma

Prevention TrialsPrevention Trials

Anti seizure medicationsAnti seizure medications HypothermiaHypothermia Magnesium Magnesium

Can PTE be PreventedCan PTE be Prevented Early seizures (1 to 7 days)Early seizures (1 to 7 days)

Immediate Sz Immediate Sz LateLate

DilantinDilantin CarbamazepineCarbamazepine PhenobarbitalPhenobarbital Levetiracetam Levetiracetam

Have all been proven to Have all been proven to be effective in be effective in decreasing the decreasing the frequency of early pot-frequency of early pot-traumatic seizures, traumatic seizures, however none have however none have shown the decrease the shown the decrease the incidence of PTEincidence of PTE

Trauma

7 days

AnimalsAnimals

Effect of treatment on the epileptogenesis Effect of treatment on the epileptogenesis after TBI in experimental modelsafter TBI in experimental models

Rimonabant sinRimonabant sinngle dose6 wk ngle dose6 wk Echegoyen et Echegoyen et

Minozac Minozac 6 h post-TBI two doses7 d 6 h post-TBI two doses7 d Chrzaszcz Chrzaszcz et al.et al. 48 48

Ketogenic diet SKetogenic diet Schwartzkroin et chwartzkroin et

HypothermiaHypothermiaParasagittal FP30 min post-TBI for Parasagittal FP30 min post-TBI for 4 h12 wk 4 h12 wk Atkins et al.Atkins et al.  

HypothermiaHypothermia

No studies in humanNo studies in human

MagnesiumMagnesium

No studies in humans No studies in humans

ConclusionsConclusions