eMedicine Specialties > Neurology > Seizures and Epilepsy

Posttraumatic Epilepsy: Differential Diagnoses & Workup

Author: Ewa Posner, MD, MRCP, Consultant Pediatrician, Department of Pediatrics, University Hospital of North Durham, UK
Coauthor(s): Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Contributor Information and Disclosures

Updated: Oct 22, 2009

Differential Diagnoses

Absence Seizures
Frontal Lobe Epilepsy
Benign Childhood Epilepsy
Head Injury
Benign Neonatal Convulsions
Neonatal Seizures
Complex Partial Seizures
Psychogenic Nonepileptic Seizures
Confusional States and Acute Memory Disorders
Temporal Lobe Epilepsy
Dizziness, Vertigo, and Imbalance
Tonic-Clonic Seizures
Febrile Seizures
First Seizure in Adulthood: Diagnosis and Treatment
First Seizure: Pediatric Perspective

Other Problems to Be Considered

Seizures due to causes other than brain injury

Pseudoseizures: Apparent seizure disorder may occur after head injury, but video EEG shows that the nature of the seizures is psychogenic rather than epileptic. For example, in patients with moderate traumatic brain injury with refractory posttraumatic epilepsy, about 20-30% were found to have been misdiagnosed and have psychogenic attacks.3 This percentage is similar to patients with nontraumatic brain injury seizure. Therefore, if atypical features and seizures continue despite treatment, the diagnosis should be verified by video EEG rather then assuming the patient has posttraumatic epilepsy.

Workup

Laboratory Studies

  • In a patient who is still hospitalized after a recent head injury, investigation of a seizure should focus on determining whether an intracranial bleed or a change in clinical condition (eg, hyponatremia) cause the seizure.
  • In a patient in otherwise stable condition whose serum electrolytes are within the normal range and whose neurologic findings are the same as those before the seizure, further laboratory studies are not needed.
  • In a patient presenting some time after the injury, the usual investigations that are applicable for the first epileptic seizure should be performed.
  • Serum prolactin measurement can be done after the seizure to help differentiate pseudoseizures from seizures. However, this is still more of a research point rather then a well-recognized standard test.

Imaging Studies

  • Brain MRI is the study of choice, and many clinicians perform it in all patients with PTS.
  • If MRI is not readily available, head CT can be substituted. CT is less sensitive than MRI, but should be able to depict all pathology (eg, intracranial bleed) that needs urgent intervention.

Other Tests

  • EEG is useful mainly for localizing seizure foci and for prognosticating their severity.
  • EEG is not helpful in predicting the likelihood of PTS in a given patient. However, it may be helpful in predicting relapse before anticonvulsant medication is withdrawn.
  • Video EEG may be helpful in differentiating between pseudoseizures and posttraumatic epilepsy seizures.

More on Posttraumatic Epilepsy

Overview: Posttraumatic Epilepsy
Differential Diagnoses & Workup: Posttraumatic Epilepsy
Treatment & Medication: Posttraumatic Epilepsy
Follow-up: Posttraumatic Epilepsy
References
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References

  1. Mori A, Yokoi I, Noda Y, Willmore LJ. Natural antioxidants may prevent posttraumatic epilepsy: a proposal based on experimental animal studies. Acta Med Okayama. Jun 2004;58(3):111-8. [Medline].

  2. Skandsen T, Ivar Lund T, Fredriksli O, Vik A. Global outcome, productivity and epilepsy 3--8 years after severe head injury. The impact of injury severity. Clin Rehabil. Jul 2008;22(7):653-62. [Medline].

  3. Hudak AM, Trivedi K, Harper CR, Booker K, Caesar RR, Agostini M, et al. Evaluation of seizure-like episodes in survivors of moderate and severe traumatic brain injury. J Head Trauma Rehabil. Jul-Aug 2004;19(4):290-5. [Medline].

  4. Temkin NR, Dikmen SS, Wilensky AJ. A randomized, double-blind study of phenytoin for the prevention of post-traumatic seizures. N Engl J Med. Aug 23 1990;323(8):497-502. [Medline].

  5. Milligan TA, Hurwitz S, Bromfield EB. Efficacy and tolerability of levetiracetam versus phenytoin after supratentorial neurosurgery. Neurology. Aug 26 2008;71(9):665-9. [Medline].

  6. Angeleri F, Majkowski J, Cacchio G, et al. Posttraumatic epilepsy risk factors: one-year prospective study after head injury. Epilepsia. Sep 1999;40(9):1222-30. [Medline].

  7. Annegers JF, Hauser WA, Coan SP, et al. A population-based study of seizures after traumatic brain injuries. N Engl J Med. Jan 1 1998;338(1):20-4. [Medline].

  8. Beghi E. Overview of studies to prevent posttraumatic epilepsy. Epilepsia. 2003;44 Suppl 10:21-6. [Medline].

  9. Chang BS, Lowenstein DH. Practice parameter: antiepileptic drug prophylaxis in severe traumatic brain injury: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. Jan 14 2003;60(1):10-6. [Medline].

  10. Chang BS, Lowenstein DH. Practice parameter: antiepileptic drug prophylaxis in severe traumatic brain injury: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. Jan 14 2003;60(1):10-6. [Medline].

  11. D'Ambrosio R, Perucca E. Epilepsy after head injury. Curr Opin Neurol. Dec 2004;17(6):731-5. [Medline].

  12. Frey LC. Epidemiology of posttraumatic epilepsy: a critical review. Epilepsia. 2003;44 Suppl 10:11-7. [Medline].

  13. Garga N, Lowenstein DH. Posttraumatic epilepsy: a major problem in desperate need of major advances. Epilepsy Curr. Jan-Feb 2006;6(1):1-5. [Medline].

  14. Schierhout G, Roberts I. Anti-epileptic drugs for preventing seizures following acute traumatic brain injury. Cochrane Database Syst Rev. 2001;CD000173. [Medline].

  15. Temkin NR. Prophylactic Anticonvulsants After Neurosurgery. Epilepsy Curr. Jul 2002;2(4):105-107. [Medline].

  16. Temkin NR, Dikmen SS, Anderson GD, et al. Valproate therapy for prevention of posttraumatic seizures: a randomized trial. J Neurosurg. Oct 1999;91(4):593-600. [Medline].

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Further Reading

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Keywords

PTE, head injury, head trauma, posttraumatic seizure, PTS, traumatic brain injury, TBI

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Contributor Information and Disclosures

Author

Ewa Posner, MD, MRCP, Consultant Pediatrician, Department of Pediatrics, University Hospital of North Durham, UK
Ewa Posner, MD, MRCP is a member of the following medical societies: European Paediatric Neurology Society and Royal College of Paediatrics and Child Health
Disclosure: Nothing to disclose.

Coauthor(s)

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

Medical Editor

Joseph F Hulihan, MD, Vice President, Medical Affairs, Ortho-McNeil Janssen Scientific Affairs, LLC
Joseph F Hulihan, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, American Headache Society, and American Medical Association
Disclosure: Johnson & Johnson Salary Employment; Johnson & Johnson Stock Employment

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Jose E Cavazos, MD, PhD, FAAN, Associate Professor with Tenure, Departments of Neurology, Pharmacology, and Physiology, University of Texas Health Science Center at San Antonio; Co-Director, South Texas Comprehensive Epilepsy Center; Director of the Epilepsy Center, Audie L Murphy Veterans Affairs Medical Center
Jose E Cavazos, MD, PhD, FAAN is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, and Society for Neuroscience
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

 
 
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