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Posttraumatic seizures

Posttraumatic seizures. อ.นพ.ธัญญา นรเศรษฐ์ธาดา หน่วยประสาทศัลยศาสตร์ ภาควิชาศัลยศาสตร์ โรงพยาบาลมหาราชนครเชียงใหม่. 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.

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Posttraumatic seizures

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  1. Posttraumatic seizures อ.นพ.ธัญญา นรเศรษฐ์ธาดา หน่วยประสาทศัลยศาสตร์ ภาควิชาศัลยศาสตร์ โรงพยาบาลมหาราชนครเชียงใหม่

  2. Post trauma serizures I Impact seizures : within 24 hours II Early seizures : within 1 week III Late seizures : more than 8 days

  3. Sequence of seizures : Hypoxia : Increased metabolic demand : Hypertension : Metabolic changes : Increased IC hypertension : Excess neurotransmitter release : Unconscious

  4. Incidence : • PTE related to severity of injury 3%-5% in the first year 12 times as great as for the population • Severe head trauma, cortical injury, neurologi deficit and • - dura intact ; 7% -39% • - dura penetration ; 20%-57%

  5. Early PTS • Incidence 2%-7% • Unselected patients with head injury ~ 2% • Consecutive admissions ~3%-6% • Young children under 5 years ~7%-9% • Severe head injury ~ 30% • Mild head injury ~ 1-2 % • SDH and ICH ~1/3 • EDH, depressed skull fracture and prolong amnesia ~10%

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

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

  8. Factors Associated with early post-traumatic seizures* Incidence of Early Post-traumatic Seizures (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 Epidural hematoma 17 Cortical contusion 16 Immediate seizures 28+ Linear fracture23 6 Post- traumatic amnesia greater than 24 hr23 12 No or brief unconsciousness23 6 No or brief unconsciousness, age younger 17 than 5 yr23

  9. Factors Associated with late post-traumatic seizures* Incidence of Late Post-traumatic Seizures (per Cent) Penetrating missile wound44 53 Early seizures 47 Intracerebral hematoma 40 Subdural hematoma 33 Glasgow Coma Scale score less than or 32 equal to 10 Depressed skull fracture 31 Cortical contusion 28 Epidural hematoma 26 Linear fracture26 5 Mild concussion23 <1

  10. Seizures type of Early PTS • 60%-80% focal seizure (more common in children or missile injury) • 20%-40% generalized tonic – clonic seizures • 10% of adult and 20% of children younger than 5 years with early seizures developed status epilepticus

  11. Seizures type of late PTS • 60%-70% are generalized seizures, with or without focal onset • 30%-40% are simple or complex partial seizures

  12. Prevention and Prophylaxis • 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

  13. Prevention and Prophylaxis • Clinical observation (1970-1979) • 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

  14. Prospective double – blind with placebo control • Penry and colleagues (1979) ;serizures occurrence in the treated group 21% versus 13% in control • 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

  15. Temkin et al • 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 • Observe that phenytoin was effective in preventing seizures during immediatedly after injury (1 or 2 weeks)

  16. The New England Journal of Medicine (1990) (Temkin) • Randomized, double blind study for prevention of PTE 404 patients, treatment patients 208, control 196 • Phenytoin exerts beneficial effect by reducing seizures only during the first week

  17. 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

  18. 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

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