Seizure-Related Injuries, Drowning and Vehicular Crashes – A Critical Review of the Literature

Poor midterm clinical outcomes and a high percentage of unsatisfying results are reported after seizure-related shoulder injuries, especially after posterior proximal humerus fracture-dislocations

BACKGROUND

Treating seizure-related shoulder injuries is challenging, and an evidence-based consensus to guide clinicians is lacking. The aim of this prospective single-center observational clinical trial was to evaluate the clinical results of a cohort of patients undergoing treatment of seizure-related shoulder injuries, to categorize them according to the lesion's characteristics, with special focus on patients with proximal humerus fracture-dislocations (PHFDs), and to define groups at risk of obtaining unsatisfactory results. We hypothesized that patients with a PHFD, considered the worst-case scenario among these injuries, would report worse clinical results in terms of the quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH) as compared to the other patients.

METHODS

Patients referred to a tertiary epilepsy center who have seizure-related shoulder injuries and with a minimum follow-up of 1 year were included. A quality-of-life assessment instrument (EQ-5D-5L), a district-specific patient-reported outcome measure (qDASH), and a pain assessment tool (visual analog scale [VAS]) were used for the clinical outcome evaluation. Subjective satisfaction and fear of new shoulder injuries was also documented. Categorization and subgroup analysis according to the presence and features of selected specific lesions were performed.

RESULTS

A total of 111 patients were deemed eligible and 83 were available for follow-up (median age 38 years, 30% females), accounting for a total of 107 injured shoulders. After a median follow-up of 3.9 (1.6-8.2) years, overall moderate clinical results were reported. In addition, 34.1% of the patients reported a VAS score ≥35 mm, indicating moderate to severe pain, and 34.1% a qDASH score ≥40 points, indicating severe disability of an upper limb. These percentages rose to, respectively, 45.5% and 48.5% in the subgroup of patients with PHFDs and to 68.8% and 68.8% in patients experiencing posterior PHFD. Overall, 46.9% of the patients considered themselves unsatisfied with the treatment and 62.5% reported a persistent fear of a new shoulder injury.

CONCLUSIONS

Patients with seizure-related shoulder injuries reported only moderate clinical results at their midterm follow-up. Older age, male sex, and absence or discontinuation of antiepileptic drug (AED) treatment were identified as characterizing features of patients with posterior dislocation episodes. In patients with PHFD, a tendency to worse clinical results was observed, with posterior PHFD patients emerging as a definite subgroup at risk of reporting unsatisfying results after treatment.

Epidemiology and specific features of shoulder injuries in patients affected by epileptic seizures

PURPOSE

Epileptic seizures can cause multiple shoulder injuries, the most common of which are dislocations, recurrent instability, fractures, and isolated lesions of the rotator cuff. Currently, only limited literature exists which describes the frequency and types of lesions in cohorts of epileptic patients and the corresponding treatment outcome. This study aims to document the occurrence of shoulder lesions in patients affected by seizures and to provide detailed information on trauma dynamics, specific lesion characteristics and treatment complications.

METHODS

All patients referring to a tertiary epilepsy center were screened for shoulder injuries and the clinical records of those sustaining them during a seizure were reviewed. Demographic information, lesions' characteristics and trauma dynamics were analysed, as wells as-when carried out-the type of surgical intervention and any postoperative complications.

RESULTS

The average age at the time of injury of 106 included patients was 39.7 ± 17.5 years and a male predominance was recorded (65%). Bilateral injuries occurred in 29 patients, simultaneously in 17 cases. A younger age, bilateral shoulder injuries and shoulder dislocations were significantly associated with the occurrence of a shoulder injury solely by muscular activation (p = 0.0054, p = 0.011, p < 0.0001). The complication rate in 57 surgically treated patients with follow-up data was 38.7%, with recurring instability being the most frequently reported complication (62.5%).

CONCLUSIONS

Uncontrolled muscle activation during a seizure is a distinctive but not exclusive dynamic of injury in epileptic patients, accounting for more than the half of all shoulder lesions, especially in the younger. This can lead both to anterior and posterior dislocations or fracture-dislocations and is frequently cause of bilateral lesions and of instability recurrence after surgery. The high complication rates after surgical treatment in this selected subgroup of patients require that appropriate preventative measures are taken to increase the probability of treatment success.

LEVEL OF EVIDENCE

Cohort study, level III.

Absence epilepsy: Characteristics, pathophysiology, attention impairments, and the related risk of accidents. A narrative review

OBJECTIVE

Absence epilepsy (AE) is related to both cognitive and physical impairments. In this narrative review, we critically discuss the pathophysiology of AE and the impairment of attention in children and adolescents with AE. In particular, we contextualize the attentive dysfunctions of AE with the associated risks, such as accidental injuries.

DATA SOURCE

An extensive literature search on attention deficits and the rate of accidental injuries in AE was run. The search was conducted on Scopus, Pubmed, and the online libraries of the University of Twente and Maastricht University. Relevant references of the included articles were added. Retrospective and prospective studies, case reports, meta-analysis, and narrative reviews were included. Only studies written in English were considered. Date of last search is February 2020. The keywords used were "absence epilepsy" AND "attention"/"awareness", "absence epilepsy" AND "accidental injuries"/"accident*"/"injuries".

RESULTS

Ten retrospective and two prospective studies on cognition and AE were fully screened. Seventeen papers explicitly referring to attention in AE were reviewed. Just one paper was found to specifically focus on accidental injuries and AE, while twelve studies generally referring to epilepsy syndromes - among which AE - and related accidents were included.

CONCLUSION

Absence epilepsy and attention deficits show some patterns of pathophysiological association. This relation may account for dysfunctions in everyday activities in the pediatric population. Particular metrics, such as the risk related to biking in children with AE, should be used in future studies to address the problem in a novel way and to impact clinical indications.

Postictal syndrome: The forgotten continent. An overview of the clinical, biochemical and imaging features

Postictal syndrome (PIS) encompasses the clinical, biological, electroencephalographic (EEG) and magnetic resonance imaging (MRI) signs that follow the termination of a seizure. These signs occur as soon as the epileptic discharge ends, but might remain for a substantially long period of time, making them amenable to clinical observation. As a direct consequence, neurologists and intensivists are more frequently attending patients with PIS than during their seizure. Moreover, careful PIS documentation may help physicians to diagnose epileptic seizure from other non-epileptic disorders. Careful analysis of PIS could also be helpful to better characterize the seizure (seizure subtypes, and to some extent, the localization and/or lateralization of the seizure). This article aims to review the main clinical, biological, EEG and MRI components of PIS, discuss differential diagnoses and propose a general clinical attitude, based on the acronym "WAITTT": W for "Watch", to monitor and investigate PIS in order to provide relevant information on seizure, AIT for "Avoid Inappropriate Treatment", to underscore the risk carrying out unnecessary drug injections and intensive care procedures in the setting of a self-limited symptomatology, and TT for "Take Time", to keep in mind that time remains the clinician's best ally for treating patients with PIS.

Accidental injuries in patients with generalized tonic-clonic seizures. A multicenter, observational, cross-sectional study (QUIN-GTC study)

PURPOSE

Patients with epilepsy have a higher risk of accidental injuries. The aim of this study was to determine the incidence of accidental injuries and quality of life in patients with epilepsy and generalized tonic-clonic seizures and their association with patient-related factors.

METHODS

This is an observational, cross-sectional, multicenter study of patients with epilepsy and primary generalized tonic-clonic seizures and/or focal to bilateral tonic-clonic seizures in the routine clinical practice of epilepsy clinics. In a single visit, demographic and clinical data and information on the type and severity of injuries were collected, and patients' quality of life was evaluated with the QOLIE-10 questionnaire.

RESULTS

In total, 406 patients with a median age of 41.1 years (range: 13-87) were included; 47.5% were women. Age at onset of tonic-clonic seizures was 25.4 (range: 0-83) years. Epileptic seizures were primary tonic-clonic (67.2%), focal to bilateral tonic-clonic (32.8%), focal with impairment of awareness (23.6%), focal without impairment of awareness (13.5%), absences (14.8%), and myoclonic (9.6%). Etiology was symptomatic or with unknown etiology focal (42.9%), genetic generalized (36.9%), symptomatic or with unknown etiology generalized (18.0%), and others (2.2%). The number of generalized tonic-clonic seizures in the last 12 months was as follows: 1 (41.9%), 2-5 (42.4%), and >5 (15.8%). Antiepileptic treatment at the time of the visit was monotherapy in 44.1% of the patients. The most commonly used drugs were levetiracetam (45.1%), valproate (20.7%), lamotrigine (20.0%), and perampanel (18.7%). In total, 59.6% of the patients had experienced at least one accidental injury associated with tonic-clonic seizures in the last 12 months, the most common being head injuries (35.5%), dental injuries (4.9%), burns (4.9%), and fractures (3.9%). A total of 25.1% had suffered at least one serious injury. The multiple logistic regression model showed that the factors associated with suffering an injury were the following: etiology (symptomatic or with unknown etiology focal and genetic generalized vs. symptomatic or with unknown etiology generalized, p = 0.0008 and p = 0.0077, respectively), number of seizures in the last year (2-5 vs. 1, p = 0.0115; >5 vs. 1, p = 0.0004), and psychiatric comorbidities (p = 0.0151). Patients with injuries had a worse quality of life than patients without injuries, according to the overall QOLIE-10 score (p = 0.0003).

CONCLUSIONS

More than half of the patients had accidental injuries related with seizures. Symptomatic or with unknown etiology focal epilepsy and genetic generalized epilepsy, >1 seizure in the last year, and concomitant psychiatric disease are the risk factors associated with accidental injuries in patients with tonic-clonic seizures, with the consequent worsening of quality of life.

Risk factors for injury in a community-treated cohort of patients with epilepsy in Australia

OBJECTIVE

There remains a paucity of knowledge regarding specific epilepsy-related risk factors for accidents and injuries in people with epilepsy. Injury studies in people with epilepsy are overrepresented, with tertiary based populations that are prone to bias from severe disease. This study aims to assess the contribution of epilepsy-related risk factors to injuries in a community-based cohort.

METHODS

We performed a retrospective nested case-control study on patients recruited into the Tasmanian Epilepsy Register (TER) from July 1, 2001 to June 30, 2002. The TER is a community-based cohort of patients with epilepsy in Tasmania, Australia, recruited from the national prescription database and interviewed for epilepsy diagnosis, injuries, and risk factors using validated questionnaires with diagnosis made by an epilepsy specialist. The primary outcome measures were lifetime and recent 12-month injury. Multivariate logistic regression with multiple imputation modeling responder nondisclosure was performed, adjusting for age, gender, region, socioeconomic status, seizure frequency, and epilepsy duration.

RESULTS

A total of 819 patients with epilepsy were included in this study. Ten percent of patients experienced an injury in the preceding year. Before adjusting for seizure frequency, any seizure over the past 12 months was associated with recent injury (adjusted odds ratio [OR] = 7.90, 95% confidence interval [CI] = 4.17-14.96). Impaired awareness, cluster seizures, sleep-only seizures, and convulsive seizure were characteristics found to significantly influence injuries irrespective of seizure frequency. Although a warning appeared initially protective for recent injuries (OR = 0.39, 95% CI = 0.22-0.69), this was entirely explained by seizure frequency, with the effect becoming nonsignificant.

SIGNIFICANCE

Likely due to their unpredictable nature, seizures expose patients with epilepsy to a high risk of life-threatening injury. These findings emphasize the importance of seizure freedom for maximizing the safety of patients with epilepsy.

Weather as a risk factor for epileptic seizures: A case-crossover study

OBJECTIVE

Most epileptic seizures occur unexpectedly and independently of known risk factors. We aimed to evaluate the clinical significance of patients' perception that weather is a risk factor for epileptic seizures.

METHODS

Using a hospital-based, bidirectional case-crossover study, 604 adult patients admitted to a large university hospital in Central Germany for an unprovoked epileptic seizure between 2003 and 2010 were recruited. The effect of atmospheric pressure, relative air humidity, and ambient temperature on the onset of epileptic seizures under temperate climate conditions was estimated.

RESULTS

We found a close-to-linear negative correlation between atmospheric pressure and seizure risk. For every 10.7 hPa lower atmospheric pressure, seizure risk increased in the entire study population by 14% (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.01-1.28). In patients with less severe epilepsy treated with one antiepileptic medication, seizure risk increased by 36% (1.36, 1.09-1.67). A high relative air humidity of >80% increased seizure risk in the entire study population by up to 48% (OR 1.48, 95% CI 1.11-1.96) 3 days after exposure in a J-shaped association. High ambient temperatures of >20°C decreased seizure risk by 46% in the overall study population (OR 0.54, 95% CI 0.32-0.90) and in subgroups, with the greatest effects observed in male patients (OR 0.33, 95% CI 0.14-0.74).

SIGNIFICANCE

Low atmospheric pressure and high relative air humidity are associated with an increased risk for epileptic seizures, whereas high ambient temperatures seem to decrease seizure risk. Weather-dependent seizure risk may be accentuated in patients with less severe epilepsy. Our results require further replication across different climate regions and cohorts before reliable clinical recommendations can be made.

Myotendinous rupture of temporalis muscle: A rare injury following seizure

Seizures are one of the most common pediatric neurologic disorders. Many complications secondary to seizures have been described in the literature including head trauma, fractures, drowning and burns. However, to the best of our knowledge, rupture of the myotendinous insertion of the temporalis muscle on the mandible secondary to a seizure has never been described in the literature. We report the case of a unilateral temporalis muscle rupture in a 16-year-old boy who developed unilateral facial swelling following new onset tonic-clonic seizures. We emphasize on the computed tomography and magnetic resonance imaging findings in this case report. Two mechanisms have been proposed to explain such an injury. The favored mechanism in our patient is a pull on the temporalis myotendinous insertion on the mandible following vigorous and brisk deviation of the head and neck during seizure. Radiologists should be familiar with this type of injury following seizures in order to prevent misdiagnosis and subsequently mistreatment.