Posttraumatic Epilepsy Treatment & Management

Early posttraumatic seizure (PTS) should be treated promptly, as seizure activity is likely to further damage the already-compromised brain. IV phenytoin and sodium valproate are the antiepileptic drugs (AEDs) of choice and are usually effective in stopping the seizure.

With late PTS, treatment is not mandatory. Some patients with a low frequency of seizures may choose not to take regular medication; in any case, compliance with long-term treatment is often poor in this group of patients. Surgical treatment is an option for PTE refractory to medication.

Treatment of posttraumatic epilepsy (PTE) does not require hospitalization. Admission may be needed for the treatment of status epilepticus or for videotelemetry to assist in the diagnosis.

Go to Epilepsy and Seizures for an overview of this topic.

The anticonvulsant usually prescribed is sodium valproate, phenytoin, or carbamazepine. To the authors' knowledge, no randomized controlled studies have been performed to prove that one AED is better than another. Some authors also recommend phenytoin,^[11] but it seems to increase the risk of impairing cognitive function. Newer AEDS—particularly, topiramate and levetiracetam—are showing promise in this regard.^[12]

Go to Antiepileptic Drugs for complete information on this topic.

Surgical treatment of PTE, as in other types of epilepsy, has the goal of excision of the epileptogenic focus. Precise identification and excision of the focus is often more difficult in PTE than in other types of epilepsy.

Go to Epilepsy Surgery for complete information on this topic.

Prevention of PTE starts with prevention of head trauma. Clinicians should encourage preventive strategies, such as use of child seats and the use of helmets when cycling.

A guideline from the American Academy of Neurology notes that in adult patients with severe traumatic brain injury, prophylaxis with phenytoin is effective in decreasing the risk of early PTS; however, AED prophylaxis is probably not effective in decreasing the risk of late PTS (ie, PTS occurring beyond 7 days after injury).^[13] Long-term AED treatment should be considered only after a diagnosis of PTE has been made.^[14]

Similarly, a 2001 Cochrane Review concluded that although prophylactic use of AEDs soon after head injury reduces early seizures, there is no evidence that it reduces late seizures or has any effect on death or neurological disability.^[15]

A study of seizure prophylaxis in patients with severe traumatic brain injury or subarachnoid hemorrhage found that intravenous levetiracetam appeared to be an alternative to fosphenytoin in that setting.^[16] Ongoing clinical trials are addressing the antiepileptogenic potential of topiramate and levetiracetam in patients with traumatic brain injury.^[12]

Administration of AEDs for the first week after neurosurgery is a routine practice.^[17] Phenytoin has most often been used for this purpose, but levetiracetam is gaining popularity; it appears to be as effective, with fewer adverse effects.^[18]

Some have proposed the existence of a window of opportunity of about 1 hour after traumatic brain injury. During this period, treatment with an AED (eg, sodium valproate) may prevent or abort the epileptogenic process.^[19] Studies to explore such treatment are under way.

Some natural antioxidants, such as alpha-tocopherol and condensed tannins, have been demonstrated to be prophylactic for the occurrence of epileptic discharge in the iron-injected animal brain.^[20]

Consult a neurologist to confirm the diagnosis. Consult a neuropsychologist to document the patient's baseline function before antiepileptic medication is started. Consultation with a neuropsychologist should be a part of the workup if surgery is considered.

Regular follow-up should be performed for a review of medications; for neuropsychological assessment; and for monitoring of adverse effects, drug levels if indicated, and the patient's neurologic status.

The Vietnam Head Injury Study (VHIS) followed more than 1,200 Vietnam veterans over a 30-year period who sustained mostly penetrating head injuries. The VHIS concluded that patients with penetrating head injuries carry a high risk of PTE decades after their injury. Predictors of PTE include lesion location (particularly if the location includes the left parietal lobe), lesion size, lesion type, and retained ferric metal fragments. Those patients will require long-term medical follow-up.^[8]