Seizures prophylaxis in Traumatic Brain Injury

Authors:

Tooba Kashif MBBS, MD,

Junaid Kalia MD

Introduction

• Traumatic brain injury (TBI) presents frequently to the emergency departments visits and is associated with increase risks of seizures.

• It requires effective prevention to improve the outcomes in patients recovering from traumatic brain injury.

• However, late onset seizures increases the likelihood of progression to epilepsy.

• Prophylactic administration of Anti-Seizure Medications (ASMs) is used as a measure to decrease the risks of post-traumatic seizures and progression into post-traumatic epilepsy (PTE).

• PTE accounts for 10-20% of epilepsy cases in general population

Early Post-traumatic seizures:

• Early seizures occurs within 7 days following traumatic brain injury

Factors associated with Early Post-traumatic seizures

• Depressed skull fracture

• Contusion

• Surgery for Intra-cerebral hematoma

• Subdural hematoma

• Penetrating brain injury

• Glasgow coma scale<10

• Young children

Prognosis

• Patients who had early seizures and at increased risk of developing PTE.

Management

• ASM is recommend for short term (7-10 Days) in patients with loss of awareness due to TBI

• Phenytoin is the only recommended treatment for seizure prophylaxis.

• IV Levetiracetam is also increasingly being used as a seizure prophylaxis because of favourable pharmacokinetics and pharmacodynamics.

• A meta-analysis study by Yong et al failed to show superior safety and efficacy of Levetiracetam compared to phenytoin for early and late seizures prophylaxis.

Late Post-traumatic seizures/ Post-traumatic Epilepsy

Prognosis

Management

Guidelines on the management of seizures prophylaxis following TBI - Brain Trauma Foundation

LEVEL I

• There was insufficient evidence to support a Level I recommendation for seizures prophylaxis.

LEVEL II A

• Prophylactic use of phenytoin/valproate is not recommended for preventing late post traumatic seizures (PTS).

• Phenytoin is recommended to decrease the incidence of early PTS (within 7 days of injury), when the overall benefit is felt to outweigh the complications associated with such treatment.

• However, early PTS have not been associated with worse outcomes.

• At the present time there is insufficient evidence to recommend levetiracetam over phenytoin regarding efficacy in preventing early post-traumatic seizures/toxicity.

Further Reading

• Beghi E. (2003). Overview of studies to prevent posttraumatic epilepsy. Epilepsia, 44(s10), 21–26. https://doi.org/10.1046/j.1528-1157.44.s10.1.x

Bibliography

• Chartrain, A. G., Yaeger, K., Feng, R., Themistocleous, M. S., Dangayach, N. S., Margetis, K., & Hickman, Z. L. (2017). Antiepileptics for Post-Traumatic Seizure Prophylaxis after Traumatic Brain Injury. Current pharmaceutical design, 23(42), 6428–6441. https://doi.org/10.2174/1381612823666171031100139

• Lucke-Wold, B. P., Nguyen, L., Turner, R. C., Logsdon, A. F., Chen, Y. W., Smith, K. E., Huber, J. D., Matsumoto, R., Rosen, C. L., Tucker, E. S., & Richter, E. (2015). Traumatic brain injury and epilepsy: Underlying mechanisms leading to seizure. Seizure, 33, 13–23. https://doi.org/10.1016/j.seizure.2015.10.002

• Temkin N. R. (2003). Risk factors for posttraumatic seizures in adults. Epilepsia, 44(s10), 18–20. https://doi.org/10.1046/j.1528-1157.44.s10.6.x

• Yang, Y., Zheng, F., Xu, X., & Wang, X. (2016). Levetiracetam Versus Phenytoin for Seizure Prophylaxis Following Traumatic Brain Injury: A Systematic Review and Meta-Analysis. CNS drugs, 30(8), 677–688. https://doi.org/10.1007/s40263-016-0365-0

• Guidelines for the Management of Severe TBI, 4th Ed. https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/:guideline/11-seizure-prophylaxis