Posttraumatic seizures management

Posttraumatic seizures management

Patient selection for seizure prophylaxis after traumatic brain injury (TBI) and duration of antiepileptic drug treatment for patients with early posttraumatic seizures (PTS) remain plagued with uncertainty. In early 2017, a collaborative group of neurosurgeons, neurologists, neurointensive care and rehabilitation medicine physicians was formed in the UK with the aim of assessing variability in current practice and gauging the degree of uncertainty to inform the design of future studies. The survey results demonstrated the variation in practice and uncertainty in both described aspects of management of patients who have suffered a TBI. The majority of respondents would want to participate in future research to help try and address this critical issue, and this shows the importance and relevance of these two clinical questions 1)

Recommendations

Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition:

Level I

• There was insufficient evidence to support a Level I recommendation for this topic.

Level II A

• Prophylactic use of phenytoin or valproate is not recommended for preventing late 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 and toxicity.

Changes from Prior Edition

The recommendations have not changed for this update from the 3rd Edition. Two new Class 2 studies and four new Class 3 studies were added as evidence, but these and the Class 3 studies included from the 3rd Edition did not provide sufficient evidence to inform new recommendations.

Prevention

Treatment

Meta-analysis

Wilson et al. assessed and compared the effectiveness of drugs on early and late PTS prevention.

A literature search revealed 120 articles. Data were included if the same factors were compared across studies with identical treatment arms. Random effects models were used for meta-analysis to combine data into an overriding odds ratio (OR) comparing PTS incidence. For early PTSs, PHT was compared with placebo and LEV with PHT. For late PTSs, each drug was compared with a placebo.

Sixteen studies were included. PHT was associated with decreased odds of early seizures relative to placebo (OR = 0.34, 95% confidence interval [CI] 0.19-0.62). There was no difference in early seizure incidence between LEV and PHT (OR = 0.83, 95% CI 0.33-2.1). Neither LEV (OR = 0.69, 95% CI 0.24-1.96) nor PHT (OR = 0.4, 95% CI 0.1-1.6) was associated with fewer late PTSs than placebo.

New literature is consistent with current guidelines supporting antiepileptic drug administration for prevention of early, but not late, PTSs. With regard to early PTS prevention, LEV and PHT are similarly efficacious, which is consistent with current guidelines. Side-effect profiles favor LEV administration over PHT 2).

References

1)

Mee H, Kolias AG, Chari A, Ercole A, Lecky F, Turner C, Tudur-Smith C, Coles J, Anwar F, Belli A, Manford M, Ham T, McMahon C, Bulters D, Uff C, Duncan JS, Wilson MH, Marson AG, Hutchinson PJ. Pharmacological management of post-traumatic seizures in adults: current practice patterns in the UK and the Republic of Ireland. Acta Neurochir (Wien). 2019 Mar;161(3):457-464. doi: 10.1007/s00701-018-3683-9. Epub 2018 Oct 1. PubMed PMID: 30276544; PubMed Central PMCID: PMC6407744.
2)

Wilson CD, Burks JD, Rodgers RB, Evans RM, Bakare AA, Safavi-Abbasi S. Early and Late Posttraumatic Epilepsy in the Setting of Traumatic Brain Injury: A Meta-analysis and Review of Antiepileptic Management. World Neurosurg. 2018 Feb;110:e901-e906. doi: 10.1016/j.wneu.2017.11.116. Epub 2017 Dec 2. Review. PubMed PMID: 29196247.

Traumatic Brain Injury: Assessment and Management

Traumatic Brain Injury: Assessment and Management

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Traumatic brain injury (TBI), also referred to as intracranial injury, occurs due to trauma to the brain. It can cause a range of physical, cognitive, behavioral, social and emotional symptoms. Its outcome can vary from complete recovery to permanent disability or death. TBI can occur due to an accident, physical violence or a fall. Its diagnosis involves the use of techniques like magnetic resonance imaging (MRI) and computed tomography. Depending on the extent of the injury, confirmed through a diagnosis, treatment can be minimal or extensive involving medications, surgery and rehabilitation therapies. This book discusses the fundamental as well as modern approaches in the assessment and management of traumatic brain injury. The topics included in this book are of utmost significance and bound to provide incredible insights to readers. It will prove to be immensely beneficial to students and researchers in this domain.

Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries

Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries

The Scandinavian Neurotrauma Committee (SNC) published practical, evidence based guidelines for children with Glasgow Coma Scale (GCS) scores of 9-15.

The Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults (Scandinavian guidelines) are the first to incorporate serum measurement of the S100 astroglial calcium-binding protein B (S100B) to emergency department (ED) triage of patients with head injury (HI).

1).


A prospective validation study was conducted in the ED of the Tampere University Hospital, Finland, between November 2015 to November 2016. All consecutive adult patients with HI presenting to the ED within 24 hours from injury were eligible for inclusion. Venous blood for S100B sampling was drawn from all patients and the result was available at the ED. Head CTs were performed according to the on-call physician’s evaluation. Only the samples collected within 6 hours after injury were used. A one-week follow-up was conducted to identify possible HI-related complications. A total of 295 patients (median age=67.0 years, range=18-100; women=48.8%) were enrolled. Of those, 196 (66.4%) were scanned. Acute traumatic lesions were detected on 31 (15.8%) of the scans. Two of the CT-positive patients were scanned without a guidelines-based indication. These lesions did not require any specific treatment or repeated imaging. The guidelines-based sensitivity was 0.94 (95% CI=0.77-0.99) and specificity 0.19 (95% CI=0.13-0.26) for predicting traumatic intracranial CT abnormalities. The positive and negative predictive value for positive head CT was 0.18 (95% CI=0.12-0.25) and 0.94 (95% CI=0.78-0.99), respectively. In the mild-low risk group, no false negative S100B values were recorded. Thirteen patients (4.4%) were re-admitted to the ED and 2 patients (0.7%) died one week after the primary HI. The deaths were unrelated to the injury. None of these adverse events were directly caused by a primarily undiagnosed intracranial injury. The Scandinavian guidelines incorporated with S100B are a valid means of screening clinically significant acute traumatic lesions following HI and have the potential to reduce unnecessary CT scanning 2).


In a large prospective cohort of children (< 18 years) with TBI of all severities, from ten Australian and New Zealand hospitals, was used to assess the SNC guidelines. Firstly, a validation study was performed according to the inclusion and exclusion criteria of the SNC guideline. Secondly, they compared the accuracy of SNC, CATCH, CHALICE and PECARN CDRs in patients with GCS 13-15 only. Diagnostic accuracy was calculated for outcome measures of need for neurosurgery, clinically important TBI (ciTBI) and brain injury on CT.

The SNC guideline could be applied to 19,007/20,137 of patients (94.4%) in the validation process. The frequency of ciTBI decreased significantly with stratification by decreasing risk according to the SNC guideline. Sensitivities for the detection of neurosurgery, ciTBI and brain injury on CT were 100.0% (95% CI 89.1-100.0; 32/32), 97.8% (94.5-99.4; 179/183) and 95% (95% CI 91.6-97.2; 262/276), respectively, with a CT/admission rate of 42% (mandatory CT rate of 5%, 18% CT or admission and 19% only admission). Four patients with ciTBI were missed; none needed specific intervention. In the homogenous comparison cohort of 18,913 children, the SNC guideline performed similar to the PECARN CDR, when compared with the other CDRs.

The SNC guideline showed a high accuracy in a large external validation cohort and compares well with published CDRs for the management of paediatric TBI 3).

References

1)

Ingebrigtsen T, Romner B, Kock-Jensen C. Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. The Scandinavian Neurotrauma Committee. J Trauma. 2000 Apr;48(4):760-6. PubMed PMID: 10780615.
2)

Minkkinen M, Iverson GL, Kotilainen AK, Pauniaho SL, Mattila V, Lehtimäki T, Berghem K, Posti JP, Luoto TM. Prospective Validation of the Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults. J Neurotrauma. 2019 May 21. doi: 10.1089/neu.2018.6351. [Epub ahead of print] PubMed PMID: 31111795.
3)

Undén J, Dalziel SR, Borland ML, Phillips N, Kochar A, Lyttle MD, Bressan S, Cheek JA, Neutze J, Donath S, Hearps S, Oakley E, Dalton S, Gilhotra Y, Babl FE; Paediatric Research in Emergency Departments International Collaborative (PREDICT). External validation of the Scandinavian guidelines for management of minimal, mild and moderate head injuries in children. BMC Med. 2018 Oct 12;16(1):176. doi: 10.1186/s12916-018-1166-8. PubMed PMID: 30309392; PubMed Central PMCID: PMC6182797.
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