Post-Traumatic Epilepsy

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

2. 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

3. 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

4. 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

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

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

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

8. TBI and Seizures

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

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

11. Seizure Risk in Brain Injuries Evaluation of Seizure Risk

12. 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

13. TBI Symptoms Epilepsy Seizures, Complex Partial Simple partial seizures Secondary generalized Psychogenic Non Epileptic events, about 30 % of patient with TBI have PNES

14. 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, 

15. Humeral Fracture after generalized status epilepticus

16. Aspiration Pneumonia after GTC Seizure

17. Burns

18. 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

19. 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

20. Mechanism of injury in TBI Defining TBI and Seizure

21. “Shear” Injury

22. GSW

23. Doc: “I got a headache”….

24. Long Term: Encephalomalacia

25. Brain Trauma

26. Prevention Trials • Anti seizure medications • Hypothermia • Magnesium

27. 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 Can PTE be Prevented Trauma 7 days

28. 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.

29. Hypothermia • No studies in human

30. Magnesium • No studies in humans

31. Conclusions