Epilepsy surgery. History Definition Seizure Convulsion Epilepsy.
Post-Traumatic Epilepsy Enrique Feoli MD North East Regional Epilepsy Group 2014.
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Transcript of Post-Traumatic Epilepsy Enrique Feoli MD North East Regional Epilepsy Group 2014.
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
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)
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
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
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.