脑外伤癫痫.ppt

SeizureRiskandManagementinTBI:LearningfromExperimentalandCaseStudies,JeffreyEnglander,MDSantaClaraValleyMedicalCenterSanJose,CA95128408885-2000/fax408885-2024,PosttraumaticSeizure(PTS)RiskandManagementinTBI:Objectives,GuidelinesforPTSprophylaxis:AANS,AAPMRPredictPTSriskbasedonclinicalpresentationAnalyzetreatmentstrategiesforindividualswithlatePTSfromcasestudy,PosttraumaticSeizure(PTS)definition,Temporarybraindysfunctionwithexcessive,hypersynchronousdischargeofcorticalneuronsImmediate:first24hourspostinjuryEarlyPTS:first7daysLatePTS:afteroneweek,Epilepsy,RecurrentunprovokedseizuresTBIaccountsfor5-20%symptomaticepilepsyingeneralpopulationEarlyPTS-3-15%adults,10-15%children;17-33%developlatePTS,adultschildrenLatePTS-86%recurrentseizuresin2yrs(Haltineretal,2019),ConsumerFeedbackearly1990s:Anticonvulsants(AED),NoStandardofcare:AEDscontinuedindefinitelyMDsreluctanttodiscontinuemedications,especiallyprescribedbyanotherMDMemoryproblemsandcomplianceDrugsideeffects:ataxia,rashes,periodontalcare,hairgrowthorloss,slowedthinkingCostofmedications,laboratorytests,AANS(2019,2000)andAAPMearlyPTStreatmentdoesnotpreventlatePTSorimproveoutcomeStandard:ProphylacticanticonvulsantsnotrecommendedforpreventionoflatePTS,TraditionalRiskFactorsforlatePTS,Penetratingshrapnelinjuries,military:53%over15years(Salazar,1985)Coma3weeks:25%(Guidice,1987)EarlyPTS-latePTS:17-33%,agerelatedinsomestudiesIntracranialhematoma:Epidural,22%;subduralorintracerebral,45%(Jennett,1975),Multi-centerstudyrationale,WhatisnaturalhistorylatePTSwithnewguidelines?CTscanfindingsnotincorporatedintoriskfactorprofileinpreviousstudiesCiviliangunshotwoundsmaybedifferentfrommilitaryshrapnelwounds-seizureriskFollow-upmechanismsalreadyinplacethroughTBIModelSystemsgrants:sufficientnumbers,Hypotheses:multi-center,prospectivestudy,latePTSby2years1styearincidence2ndyearGCSinjuryseveritywillpredictlatePTSIntracraniallesionsbyCTscanpredictlatePTSDuralpenetrationpredictlatePTS,ProspectiveenrollmentofsevereTBI,Traumacenters:Denver,Richmond,Detroit,SanJose16yo,notpregnant,nopreviousseizure,stroke,tumor,intracranialsurgery;AEDsgeneralizedseizurefocalseizureStatistics:survivalanalysis,relativeriskcalculations,Timecourseandqualityoflateposttraumaticseizures,647enrolledover4years14%latePTSby2years40%occurred8-30days63%by6months80%by12months93%by18months79%generalized;21%focal,EarlyPTS(5mmmidlineshift,CorticalContusions:RelativeriskoflatePTS,Nocontusion:6%Singlecontusion:8%Bilateralormultiplecontusions:25%bifrontal:26%bitemporal:31%biparietal:66%BilateralcontusionsamongsthighestriskfactorsforlatePTS,SubcorticalcontusionsandrelativeriskforlatePTS,Nosubcorticalcontusion:13%Singlesubcorticalcontusion:16%Multiplesubcorticalcontusions:33%HighassociationofmultiplesubcorticalcontusionsandlatePTS:probablymarkerforsevereTBI.,PenetratingInjuriesandlatePTS,Nopenetratingbone,metalfragments:14%Bonefragmentsonly:0%Boneandmetalfragments:63%Metalfragments(bullets)haveaveryhighassociationwithlatePTSandarecomparabletoshrapnelinjuries.Bonefragmentsalonehaveminimalincreasedrisk.,MasslesionsandrelativeriskoflatePTS,Epiduralhematoma(EDH)noEDH:14%EDH,noevacuation:8%EDHwithevacuation:19%Subduralhematoma(SDH)noSDH:10%SDH,noevacuation:15%SDHwithevacuation:28%,NeurosurgicalproceduresandrelativeriskoflatePTS,1evacuationofintracerebralhematoma:75%1operation:37%;1operation:15%;none:11%Ventriculostomy:25%;noventriculostomy:13%Moresevereinjuriesrequiremoreneurosurgicalprocedures;thoseindividualshavehigherriskoflatePTS,LengthofphenytoinprophylaxisandrelativeriskoflatePTS,DaysDPH%RelativeriskNone7%1-7days12%8-14days17%15-30days30%*p=.0002Probablyamarkerformoresevereinjury,StudyLimitations,Duralpenetration“n”toosmall(26/647)Prolongedorlateanticonvulsantuse:sickerpatientshadtobedroppedSelfreportofsymptoms:biastoseizuresthatgeneralizeasthesearemorerecognizableConcomitantfactors:midlineshiftisoftenacriteriaforsurgery,sowhichisthepredominantriskfactor?,Conclusions,AANSandAAPMRguidelinesaresupportedMostPTSoccurin18mospostTBIGCSseverityinsufficienttopredictPTSrisk,Conclusions,Veryhighriskgroups:earlyPTS,multiplecontusions,midlineshift5mm,subduralhematomasurgery,multipleoperations,boneandmetalfragmentsIstherearoleforprophylaxisinveryhighriskgroups?Doubleblindrandomizedstudy,moreinstitutionsQualityoflife,RTW/school,independentlivinginindividualswithPTSvnone:needsstudy,RTcasestudyslide1,20yomanwithGSWtolefttemporaloccipitalareasRcavernouscarotidfistula-balloonocclusionLatePTSwhendevelopedseverehydrocephalusVentriculoperitonealshunt10weekspostinjuryAcuterehab13weekspostinjury,Rancho3-4valproateforseizureandpantoprazoleforGIprotection;cuffedtracheostomyCommunicateswitheyeblinks,fingermovementsCrN2,3,6,7,9,10,12injuriesRUEsomeselectivemovement;tremorandsynergyinLUE,bilateralLEWhatishisriskfactorprofile?Continuetotreat?,RTcasestudyslide2,Withconsentfrombrothervalproateistaperedtodecreasetremor;everyonewatchingforseizuresYoudeflatehistrachandwithin2dayschangetocufflessFoleytocondomcatheter,continuoustobolusfeedingCogwheelrigidityandtremorwithmovement,noseizuresHowdoyoutreathiscogwheelrigidityandtremor?,RTcasestudyslide3,SinemetstartedusingADLandwheelchairmobilityasperformanceparameters41/2monthspostinjury,30secondLOC,LEshakinganddifficultybreathing.ResumedpreviousleveloffunctioningwithinhoursWhatisthisepisode?Whatdiagnosticinterventionsareappropriate?,RTcasestudyslide4,ComplexpartialseizurewithrespiratorydistressNoevidenceofinfectioninlungs,urineElectrolytes(Na,Ca,Mg,CO2,BUN/Cr)normalCTscanshowedcontinuedimprovementinhydrocephalus,subduralfluidcollectionsUnprovokedseizure,associatedwithveryhighincidenceofrecurrentepisodesWhatmedicationwouldcausetheleasttoxicity?,RTcasestudyslide5,Lamotriginepickedbecauselowsedationpotential,lowincidenceofmotorsideeffectsGradualbuild-upofdoseOK,givenrapidrecoveryfromthisseizureeventOthermedicationconsiderationsValproate,phenytoin,carbamazepine:motoricsideeffectslevetiracetam:renalclearance,notsedatingoxcarbazepine:lessmotortoxicitythancarbamazepine,DKcasestudyslide1,26yoLHfemale,motorcyclecrashwhilehelmetedEMSGCS6,eyesdeviatedtoleft,bloodyvomitusinmouth,tonic-clonicmovementsinextremitiesCTscan:Rmaxillarysinusfracture,nocontusionsSocial:streetdrugarrests;sober,working2yearsWhatisthisepisode?Howshouldshebetreated?,DKcasestudyslide2,ImmediatePTSIntubatedinER;ICPmonitorshowed38mmHgICPcontrolledwithventilation,mannitolPhenytoinstartedIVFollow-upCTscan:bifrontalcontusions,LsubduralhygromaTracheostomyperformedafterfailedweaningAgitationmanagedwithlorazepamHowlongshouldshebetreatedwithAEDs?S,DKcasestudyslide3,3weekspostinjury,admissiontoacuterehabilitationtracheostomy,NGtubewithcontinuousfeedings,nonfluentaphasia,Lhemiparesis,LVFdefect,Rancho3-4,maxassistancemobilityandADLs.Meds:phenytoin,prnlorazepam,pepcidHowwouldyoumanageherrehabilitationandhermedications,DKcasestudyslide4,Regulatescheduleformobility,ADL,bolusfeeding,communicationstrategies,netbed,weantrachDCphenytoin,pepcid.Taperbenzodiazepinestoimprovelevelofalertness.Noindication.PTAresolves6weeks;safetyawarenessimproves7weekspostTBI,episodeofunresponsiveness,headandeyedeviationtoleftfor80%Drivingnotimmediateissue:VFdeficitSupportreasonablechoicebypatient,familyShedecidestotakeachancewithoutmedication,Considerationsofantiepilepticdrugchoice,Compliance:once/dayvs.multipledosesphenytoin,phenobarbitalonce/dayallothersare2-3times/dayDesiredsideeffects:moodstabilization,neuropathicpainUndesiredsideeffects:sedation,interactions,cognitiveslowing,weightgain,bloodmonitoring,hairandgingivalgrowth,Bibliography,BrainInjurySpecialInterestGroupoftheAmericanAcademyof