Posttraumatic epilepsy in chronic disorders of consciousness due to severe traumatic brain injury after traffic accidents

PURPOSE

To evaluate the clinical state of posttraumatic epilepsy (PTE) in patients with chronic disorders of consciousness (CDC) due to severe traumatic brain injury (STBI) after traffic accidents and clarify the risk factors for seizure occurrence in such patients.

METHODS

Two hundred ninety-three patients with CDC due to STBI (mean age at admission [±standard deviation]: 36.4 ± 17.9 years; men: 71.7 %; mean duration of injury to admission: 416 ± 732 days; mean hospitalization time: 899 ± 319 days) were enrolled in this study. We retrospectively investigated the relationship between seizure conditions (type and frequency) and clinical data, including age, sex, pathological types of brain injury, with/without surgical intervention, degree of CDC, and administration of antiseizure medications (ASMs).

RESULTS

Overall, 52.9 % (n = 155/293) and 64.2 % of the patients (n = 183/of 285 patients surviving at discharge) were administered ASMs at admission and discharge, respectively. One hundred thirty-two patients (45.1 %) experienced epileptic seizures during hospitalization, and the mean seizure frequency was 4.0 ± 0.4 times per year. In multivariate analysis, significant and independent risk factors of seizure occurrence were revealed to be male sex, high National Agency for Automotive Safety and Victims' Aid score, hypoxic encephalopathy, and history of the neurosurgical operations.

CONCLUSION

The high prevalence of PTE in patients with CDC due to STBI, and the significant and independent risk factors for seizure occurrence in the chronic clinical phase were revealed. We expect that this study will aid toward improving clinical assessment and management of epileptic seizures in the population.

Clinical characteristics and associated factors of posttraumatic epilepsy after traumatic brain injury in children: A retrospective case-control study

BACKGROUND

Traumatic brain injury (TBI) affects approximately 69 million individuals annually, often resulting in well-documented complications such as epilepsy. Although numerous studies have been performed on posttraumatic epilepsy (PTE) in adults over the past decade, research on chronic consequences of TBI in children remains limited. Herein, we retrospectively assessed children who had experienced moderate to severe TBI to determine their clinical characteristics and identify associated factors associated with the development of PTE in the pediatric population.

METHODS

The study population comprised children aged 0-18 years who had experienced moderate to severe TBI and underwent treatment at the Children's Hospital of Chongqing Medical University between 2011 and 2021. They were categorized into two groups: the PTE group, comprising individuals diagnosed with PTE within a one-year follow-up period, and the nPTE group, consisting of those who did not develop PTE during the same timeframe. The primary objective was to investigate the clinical characteristics and identify related associated factors. The relationship between various clinical factors and the incidence of PTE was assessed through univariate and multivariate logistic regression.

RESULTS

A total of 132 patients were assessed. Most participants were male (65%) and the age distribution skewed towards younger children, with a median age of 41.0 months (interquartile range: 45.3). Upon their last clinical visit, 64 children (49%) were diagnosed with PTE. Notably, the first posttraumatic seizure predominantly occurred within the first week following the traumatic event. Further analyses revealed that increasing injury severity, as indicated by a lower Glasgow Coma Scale (GCS) score (odds ratio [OR]: 0.78, 95% confidence interval [CI]: 0.54-1.12, p= 0.018), a contusion load ≥3 (OR: 8.1, 95% CI: 2.3-28.9, p= 0.001), immediate posttraumatic seizures (IPTS) (OR: 8.9, 95% CI: 2.5-31.2, p < 0.001), and early posttraumatic seizures (EPTS) (OR: 54, 95% CI: 11-276, p < 0.001), were all significantly associated with a higher risk of developing PTE.

CONCLUSION

This study highlights that the onset of PTE was associated with the markers of injury severity or PTS and identified GCS scores, contusion loads of ≥3, IPTS, and EPTS as independent associated factors significantly associated with the development of PTE.

Risk Factors and Incidence of Epilepsy after Severe Traumatic Brain Injury

We determined the incidence of post-traumatic epilepsy after severe traumatic brain injury. Of 392 patients surviving to discharge, cumulative incidence of post-traumatic epilepsy was 25% at 5 years and 32% at 15 years, an increase compared with historical reports. Among patients with one late seizure (>7 days post-trauma), the risk of seizure recurrence was 62% after 1 year and 82% at 10 years. Competing hazards regression identified age, decompressive hemicraniectomy, and intracranial infection as independent predictors of post-traumatic epilepsy. Patients with severe traumatic brain injury and a single late post-traumatic seizure will likely require long-term antiseizure medicines. ANN NEUROL 2022;92:663-669.

Thyroid function in the subacute phase of traumatic brain injury: a potential predictor of post-traumatic neurological and functional outcomes

PURPOSE

That thyroid hormones exert pleiotropic effects and have a contributory role in triggering seizures in patients with traumatic brain injury (TBI) can be hypothesized. We aimed at investigating thyroid function tests as prognostic factors of the development of seizures and of functional outcome in TBI.

METHODS

This retrospective study enrolled 243 adult patients with a diagnosis of mild-to-severe TBI, consecutively admitted to our rehabilitation unit for a 6-month neurorehabilitation program. Data on occurrence of seizures, brain imaging, injury characteristics, associated neurosurgical procedures, neurologic and functional assessments, and death during hospitalization were collected at baseline, during the workup and on discharge. Thyroid function tests (serum TSH, fT4, and fT3 levels) were performed upon admission to neurorehabilitation.

RESULTS

Serum fT3 levels were positively associated with an increased risk of late post-traumatic seizures (LPTS) in post-TBI patients independent of age, sex and TBI severity (OR = 1.85, CI 95% 1.22-2.61, p < 0.01). Measured at admission, fT3 values higher than 2.76 pg/mL discriminated patients with late post-traumatic seizures from those without, with a sensitivity of 74.2% and a specificity of 60.9%. Independently from the presence of post-traumatic epilepsy and TBI severity, increasing TSH levels and decreasing fT3 levels were associated with worse neurological and functional outcome, as well as with higher risk of mortality within 6 months from the TBI event.

CONCLUSIONS

Serum fT3 levels assessed in the subacute phase post-TBI are associated with neurological and functional outcome as well as with the risk of seizure occurrence. Further studies are needed to investigate the mechanisms underlying these associations.

Association of Posttraumatic Epilepsy With 1-Year Outcomes After Traumatic Brain Injury

IMPORTANCE

Posttraumatic epilepsy (PTE) is a recognized sequela of traumatic brain injury (TBI), but the long-term outcomes associated with PTE independent of injury severity are not precisely known.

OBJECTIVE

To determine the incidence, risk factors, and association with functional outcomes and self-reported somatic, cognitive, and psychological concerns of self-reported PTE in a large, prospectively collected TBI cohort.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter, prospective cohort study was conducted as part of the Transforming Research and Clinical Knowledge in Traumatic Brain Injury study and identified patients presenting with TBI to 1 of 18 participating level 1 US trauma centers from February 2014 to July 2018. Patients with TBI, extracranial orthopedic injuries (orthopedic controls), and individuals without reported injuries (eg, friends and family of participants; hereafter friend controls) were prospectively followed for 12 months. Data were analyzed from January 2020 to April 2021.

EXPOSURE

Demographic, imaging, and clinical information was collected according to TBI Common Data Elements. Incidence of self-reported PTE was assessed using the National Institute of Neurological Disorders and Stroke Epilepsy Screening Questionnaire (NINDS-ESQ).

MAIN OUTCOMES AND MEASURES

Primary outcomes included Glasgow Outcome Scale Extended, Rivermead Cognitive Metric (RCM; derived from the Rivermead Post Concussion Symptoms Questionnaire), and the Brief Symptom Inventory-18 (BSI).

RESULTS

Of 3296 participants identified as part of the study, 3044 met inclusion criteria, and 1885 participants (mean [SD] age, 41.3 [17.1] years; 1241 [65.8%] men and 644 [34.2%] women) had follow-up information at 12 months, including 1493 patients with TBI; 182 orthopedic controls, 210 uninjured friend controls; 41 patients with TBI (2.8%) and no controls had positive screening results for PTE. Compared with a negative screening result for PTE, having a positive screening result for PTE was associated with presenting Glasgow Coma Scale score (8.1 [4.8] vs.13.5 [3.3]; P < .001) as well as with anomalous acute head imaging findings (risk ratio, 6.42 [95% CI, 2.71-15.22]). After controlling for age, initial Glasgow Coma Scale score, and imaging findings, compared with patients with TBI and without PTE, patients with TBI and with positive PTE screening results had significantly lower Glasgow Outcome Scale Extended scores (mean [SD], 6.1 [1.7] vs 4.7 [1.5]; P < .001), higher BSI scores (mean [SD], 50.2 [10.7] vs 58.6 [10.8]; P = .02), and higher RCM scores (mean [SD], 3.1 [2.6] vs 5.3 [1.9]; P = .002) at 12 months.

CONCLUSIONS AND RELEVANCE

In this cohort study, the incidence of self-reported PTE after TBI was found to be 2.8% and was independently associated with unfavorable outcomes. These findings highlight the need for effective antiepileptogenic therapies after TBI.

Incidence of post-traumatic epilepsy following paediatric traumatic brain injury: protocol for systematic review and meta-analysis

INTRODUCTION

Post-traumatic epilepsy (PTE) is a recognised complication of traumatic brain injury (TBI), and is associated with higher rates of mortality and morbidity when compared with patients with TBI who do not develop PTE. The majority of the literature on PTE has focused on adult populations, and consequently there is a paucity of information regarding paediatric cohorts. Additionally, there is considerable heterogeneity surrounding the reported incidence of PTE following childhood TBI in the current literature. The primary aim of our study is to summarise reported PTE incidences in paediatric populations to derive an accurate estimate of the global incidence of PTE following childhood TBI. Our secondary aim is to explore risk factors that increase the likelihood of developing PTE.

METHODS AND ANALYSIS

A systematic literature search of Embase (1947-2021), PubMed (1996-2021) and Web of Science (1900-2021) will be conducted. Publications in English that report the incidence of PTE in populations under 18 years of age will be included. Publications that evaluate fewer than 10 patients, report an alternative cause of epilepsy, or in which a paediatric cohort is not discernable, will be excluded. Independent investigators will identify the relevant publications, and discrepancies will be adjudicated by a third independent investigator. Data extracted will include incidence of PTE, time intervals between TBI and PTE, seizure characteristics, injury characteristics, patient demographics and clinical data. Data extraction will be performed by two independent investigators and cross-checked by a third investigator. A descriptive analysis of PTE incidence will be conducted and a weighted mean will be calculated. If sufficient data are available, stratified meta-analysis of subgroups will also be conducted.

ETHICS AND DISSEMINATION

Ethics approval was not required for this study. We intend to publish our findings in a high-quality peer-reviewed journal on completion.

PROSPERO REGISTRATION NUMBER

CRD42021245802.

A review of seizures and epilepsy following traumatic brain injury

Traumatic brain injury (TBI) is one of the commonest presentations to emergency departments and is associated with seizures carrying different significance at different stages following injury. We describe the epidemiology of early and late seizures following TBI, the significance of intracranial haemorrhage of different types in the risk of later epilepsy and the gaps in current understanding of risk factors contributing to the risk of post-traumatic epilepsy (PTE). The delay from injury to epilepsy presents an opportunity to understand the mechanisms underlying changes in the brain and how they may reveal potential targets for anti-epileptogenic therapy. We review existing treatments, both medical and surgical and conclude that current research is not tailored to differentiate between PTE and other forms of focal epilepsy. Finally, we review the increasing understanding of the frequency and significance of dissociative seizures following mild TBI.

Epidemiology of traumatic brain injury-associated epilepsy and early use of anti-epilepsy drugs: An analysis of insurance claims data, 2004-2014

BACKGROUND

About 2.8 million TBI-related emergency department visits, hospitalizations and deaths occurred in 2013 in the United States. Post-traumatic epilepsy (PTE) can be a disabling, life-long outcome of TBI.

OBJECTIVES

The purpose of this study is to address the probability of developing PTE within 9 years after TBI, the risk factors associated with PTE, the prevalence of anti-epileptic drug (AEDs) use, and the effectiveness of using AEDs prophylactically after TBI to prevent the development of PTE.

METHODS

Using MarketScan® databases covering commercial, Medicare Supplemental, and multi-state Medicaid enrollees from 2004 to 2014, we examined the incidence of early seizures (within seven days after TBI) and cumulative incidence of PTE, the hazard ratios (HR) of PTE by age, gender, TBI severity, early seizure and AED use (carbamazepine, clonazepam, divalproex sodium, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, pregabalin, topiramate, acetazolamide). We used backward selection to build the final Cox proportional hazard model and conducted multivariable survival analysis to obtain estimates of crude and adjusted HR (cHRs, aHRs) of PTE and 95% confidence intervals (CI).

RESULTS

The incidence of early seizure among TBI patients in our study was 0.5%. The cumulative incidence of PTE increased from 1.0% in one year to 4.0% in nine years. Most patients with TBI (93%) were not prescribed any AED. Gender was not associated with PTE. The risk of PTE was higher for individuals with older age, early seizures, and more severe TBI. Only individuals using prophylactic acetazolamide had significantly lower risk of PTE (aHR = 0.6, CI 0.4-0.9) compared to those not using any AED.

CONCLUSION

The probability of developing PTE increased within the study period. The risk of developing PTE significantly increased with age, early seizure and TBI severity. Most of the individuals did not receive AED after TBI. There was no evidence suggesting AEDs helped to prevent PTE with the possible exception of acetazolamide. However, further studies may be needed to test the efficacy of acetazolamide in preventing PTE.

Early seizures and temporal lobe trauma predict post-traumatic epilepsy: A longitudinal study

OBJECTIVE

Injury severity after traumatic brain injury (TBI) is a well-established risk factor for the development of post-traumatic epilepsy (PTE). However, whether lesion location influences the susceptibility of seizures and development of PTE longitudinally has yet to be defined. We hypothesized that lesion location, specifically in the temporal lobe, would be associated with an increased incidence of both early seizures and PTE. As secondary analysis measures, we assessed the degree of brain atrophy and functional recovery, and performed a between-group analysis, comparing patients who developed PTE with those who did not develop PTE.

METHODS

We assessed early seizure incidence (n = 90) and longitudinal development of PTE (n = 46) in a prospective convenience sample of patients with moderate-severe TBI. Acutely, patients were monitored with prospective cEEG and a high-resolution Magnetic Resonance Imaging (MRI) scan for lesion location classification. Chronically, patients underwent a high-resolution MRI, clinical assessment, and were longitudinally monitored for development of epilepsy for a minimum of 2 years post-injury.

RESULTS

Early seizures, occurring within the first week post-injury, occurred in 26.7% of the patients (n = 90). Within the cohort of subjects who had evidence of early seizures (n = 24), 75% had a hemorrhagic temporal lobe injury on admission. For longitudinal analyses (n = 46), 45.7% of patients developed PTE within a minimum of 2 years post-injury. Within the cohort of subjects who developed PTE (n = 21), 85.7% had a hemorrhagic temporal lobe injury on admission and 38.1% had early (convulsive or non-convulsive) seizures on cEEG monitoring during their acute ICU stay. In a between-group analysis, patients with PTE (n = 21) were more likely than patients who did not develop PTE (n = 25) to have a hemorrhagic temporal lobe injury (p < 0.001), worse functional recovery (p = 0.003), and greater temporal lobe atrophy (p = 0.029).

CONCLUSION

Our results indicate that in a cohort of patients with a moderate-severe TBI, 1) lesion location specificity (e.g. the temporal lobe) is related to both a high incidence of early seizures and longitudinal development of PTE, 2) early seizures, whether convulsive or non-convulsive in nature, are associated with an increased risk for PTE development, and 3) patients who develop PTE have greater chronic temporal lobe atrophy and worse functional outcomes, compared to those who do not develop PTE, despite matched injury severity characteristics. This study provides the foundation for a future prospective study focused on elucidating the mechanisms and risk factors for epileptogenesis.

A systematic review of PTSD prevalence and trajectories in DSM-5 defined trauma exposed populations: intentional and non-intentional traumatic events

OBJECTIVE

We conducted a systematic review of the literature to explore the longitudinal course of PTSD in DSM-5-defined trauma exposed populations to identify the course of illness and recovery for individuals and populations experiencing PTSD.

METHODS

We reviewed the published literature from January 1, 1998 to December 31, 2010 for longitudinal studies of directly exposed trauma populations in order to: (1) review rates of PTSD in the first year after a traumatic event; (2) examine potential types of proposed DSM-5 direct trauma exposure (intentional and non-intentional); and (3) identify the clinical course of PTSD (early onset, later onset, chronicity, remission, and resilience). Of the 2537 identified articles, 58 articles representing 35 unique subject populations met the proposed DSM-5 criteria for experiencing a traumatic event, and assessed PTSD at two or more time points within 12 months of the traumatic event.

RESULTS

The mean prevalence of PTSD across all studies decreases from 28.8% (range =3.1-87.5%) at 1 month to 17.0% (range =0.6-43.8%) at 12 months. However, when traumatic events are classified into intentional and non-intentional, the median prevalences trend down for the non-intentional trauma exposed populations, while the median prevalences in the intentional trauma category steadily increase from 11.8% to 23.3%. Across five studies with sufficient data, 37.1% of those exposed to intentional trauma develop PTSD. Among those with PTSD, about one third (34.8%) remit after 3 months. Nearly 40% of those with PTSD (39.1%) have a chronic course, and only a very small fraction (3.5%) of new PTSD cases appears after three months.

CONCLUSIONS

Understanding the trajectories of PTSD over time, and how it may vary by type of traumatic event (intentional vs. non-intentional) will assist public health planning and treatment.

Prevalence of epileptic and nonepileptic events after pediatric traumatic brain injury

Though posttraumatic epilepsy (PTE) is a prominent sequela of traumatic brain injury (TBI), other nonepileptic phenomena also warrant consideration. Within two UCLA pediatric TBI cohorts, we categorized five spell types: 1) PTE; 2) Epilepsy with other potential etiologies (cortical dysplasia, primary generalized); 3) Psychopathology; 4) Behavior misinterpreted as seizures; and 5) Other neurologic events. The two cohort subsets differed slightly in injury severity, but they were otherwise similar. Overall, PTE occurred in 40%, other epilepsy etiologies in 14%, and nonepileptic spells collectively in 46%. Among children with spells, PTE was associated with severe TBI (p=0.001), whereas psychopathology (p=0.014) and epilepsy with other etiologies (p=0.006) were associated with milder TBI severity. Posttraumatic epilepsy (p=0.002) and misinterpreted behavior (p=0.049) occurred with younger injury age. Psychopathology (p=0.020) and other neurologic events (p=0.002) occurred with older injury age. In evaluating possible PTE, clinicians should maintain a broad differential diagnosis to prevent misdiagnosis and inappropriate treatment.

Military sexual trauma among U.S. female veterans

Sexual abuse among female veterans reportedly occurs in significant numbers in the U.S. military and has been recognized to cause posttraumatic stress disorder (PTSD). PTSD, which stems from sexual abuse, has been called military sexual trauma (MST), which has only recently been recognized by the Department of Defense. Consequently, there has been scant research on the prevalence, impact, and treatment of MST. This article explores the phenomenon of sexual aggression against female veterans in the U.S. military, risk factors for MST, PTSD as a result of MST, a conceptual framework for treating PTSD stress, and treatment strategies for PTSD.

[Disability evaluation of 204 cases of children with brain injury in road traffic accidents]

OBJECTIVE

To study the types, characteristics and common complications as well as disability assessment for the children with craniocerebral injury in the road traffic accidents.

METHODS

Data from 204 cases of children with cranio-injury in road traffic accidents were collected and were statistically analyzed according to the location injured, complication, the type of complication and the severity of disability.

RESULTS

There were 64 cases of simple diffuse primary craniocerebral injury, 80 cases of simple local primary cranio-injury, 24 cases of diffuse secondary craniocerebral injury and 36 cases of local secondary cranio-injury. The main complications included traumatic epilepsy (14, 6.9%), traumatic cerebral infarction (9, 4.4%), traumatic hydrocephalus (7, 3.4%) and traumatic mental disorder (5, 2.5%).

CONCLUSION

Among the children with cranio-injury due to road traffic accidents, simple primary cranio-injury was the most common result, whereas the traumatic epilepsy and traumatic cerebral infarction were the major types of complications. The assessment criteria for body impairment of the children with craniocerebral injury in the road traffic accidents should be broadened accordingly, with addition of certain specific items for children.

Functional outcome and health-related quality of life 10 years after moderate-to-severe traumatic brain injury

OBJECTIVES

To describe the functional outcome and health-related quality of life (HRQL) 10 years after moderate-to-severe traumatic brain injury (TBI).

MATERIAL AND METHODS

A retrospective, population-based study of 62 survivors of working-age with moderate-to-severe TBI injured in 1995/1996, and hospitalized at the Trauma Referral Center in Eastern Norway. Functional status was measured by the Glasgow Outcome Scale-Extended (GOS-E). HRQL was assessed by the SF-36 questionnaire.

RESULTS

The mean current-age was 40.8 years. The frequency of epilepsy was 19% and the depression rate 31%. A majority had good recovery (48%) or moderate disability (44%). Employment rate was 58%. Functional and employment status were associated with initial injury severity in contrast to HRQL. Study patients had significantly lower scores in all SF-36 dimensions when compared with the general Norwegian population.

CONCLUSION

At 10-years follow-up, our study population is still in their most productive years and affected domains should be considered in long-term follow-up and intervention programs.

Complications of Missile Craniocerebral Injuries during the Croatian Homeland War

OBJECTIVE

Complications of penetrating craniocerebral injuries in war can be early (during the first week after wounding) or late (after that period). Postoperative hematomas, infections, seizures, and cerebrospinal fluid fistulas (CSFFs) are counted among the early complications, whereas foreign bodies migrating intracranially, seizures, infections, and posttraumatic hydrocephalus represent late complications. A total of 176 patients with well-defined head injuries from missiles, sustained during the Croatian Homeland War (1991-1995), developed a total of 61 (34.5%) complications.

METHODS

A retrospective statistical analysis of the medical records of the patients in our series was performed to determine the risk factors for the onset of complications, which have unfavorable effects on outcomes.

RESULTS

There were a total of 28 (15.9%) infections (deep or superficial), 21 (11.9%) cases of CSFFs, 9 (5.11%) cases of early epilepsy, and 3 cases of post-traumatic hydrocephalus. A total of 47.6% of patients with CSFFs developed intracranial infections. Of eight patients with meningoencephalitis, five had CSFFs and four had intracranially retained foreign bodies. Only one patient developed a cerebral abscess. Two patients died because of infectious complications (13.3%). Post-traumatic hydrocephalus (1.7%) required shunt placement. For 60% of patients with deep-seated intracranial infectious complications and 76% of patients with CSFFs, reoperations had to be performed, whereas this was the case for only 8% of patients without infections (chi2 = 43.6, p = 0.00001).

CONCLUSIONS

Intracranially retained foreign bodies, wound age, wound site, and operations performed outside the neurosurgical services were the main risk factors for the development of complications. Complications themselves exerted a very unfavorable influence on outcomes. The development of complications reflects very reliably the neurosurgical technique applied.

Epidemiology of posttraumatic epilepsy: a critical review

PROBLEM

Traumatic brain injury (TBI) is a major cause of epilepsy. We need to understand its frequency and its contribution to the total spectrum of the convulsive disorders.

METHODS

A review of selected articles dealing with epilepsy after brain trauma was undertaken.

RESULTS

The number of epidemiologic studies of posttraumatic seizures has increased substantially over the past 40-50 years, offering steadily increasing knowledge of the frequency, natural history, and risk factors of this well-recognized complication of TBI. In general, the incidence of posttraumatic seizures varies with the time period after injury and population age range under study, as well as the spectrum of severity of the inciting injuries, and has been reported to be anywhere from 4 to 53%. As high as 86% of patients with one seizure after TBI will have a second in the next 2 years. Longer-term remission rates of 25-40% have been reported. Significant risk factors for the development of seizures in the first week after injury include acute intracerebral hematoma (especially subdural hematoma), younger age, increased injury severity, and chronic alcoholism. Significant risk factors for the development of seizures >1 week after TBI include seizures within the first week, acute intra-cerebral hematoma (especially subdural hematoma), brain contusion, increased injury severity, and age >65 years at the time of injury.

CONCLUSIONS

Epilepsy is a frequent consequence of brain injury in both civilian and military populations. We understand some factors associated with its development, but there remain many unanswered questions.

Linking posttraumatic stress disorder and psychosis: a look at epidemiology, phenomenology, and treatment

Several recent studies have provided direct evidence for the link between posttraumatic stress disorder (PTSD) and psychosis. Patients with psychotic disorders are known to be at a higher risk of traumatization and PTSD. Additionally, preclinical and clinical data suggest that the effects of trauma exposure on neural networks may provide a common diathesis for disorders like PTSD and schizophrenia. This article reviews evidence on a) the magnitude of association between PTSD and psychosis, b) the causal mechanisms implicated, and c) treatment considerations relevant to this association. A comprehensive MEDLINE search was conducted, and articles pertinent to epidemiological, clinical, and treatment aspects of comorbid PTSD and psychosis were identified. High rates of PTSD characterize patients with severe mental illness. Psychotic phenomena may also be a relatively common manifestation in patients with chronic PTSD. However, in clinical settings, the diagnosis is often missed, and few systematic guidelines exist for the identification and treatment of these comorbidities. Future neurobiological and treatment studies may be useful in better informing the clinical management of these subgroups.

Lower cortisol levels in depressed patients with comorbid post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is often comorbid with major depressive episodes (MDEs) and both conditions carry a higher rate of suicidal behavior. Hypothalamic-pituitary-adrenal (HPA) axis and serotonin abnormalities are associated with both conditions and suicidal behavior, but their inter-relation is not known. We determined cortisol response to placebo or fenfluramine in MDE, MDE and PTSD (MDE+PTSD), and healthy volunteers (HVs) and examined the relation of cortisol responses to suicidal behavior. A total of 58 medication-free patients with MDE (13 had MDE+PTSD) and 24 HVs were studied. They received placebo on the first day and fenfluramine on the second day. Cortisol levels were drawn before challenge and for 5 h thereafter. The MDE+PTSD group had the lowest plasma cortisol, the MDE group had the highest, and HVs had intermediate levels. There were no group differences in cortisol response to fenfluramine. Suicidal behavior, sex, and childhood history of abuse were not predictors of baseline or postchallenge plasma cortisol. Cortisol levels increased with age. This study finds elevated cortisol levels in MDE and is the first report of lower cortisol levels in MDE+PTSD. The findings underscore the impact of comorbidity of PTSD with MDE and highlight the importance of considering comorbidity in psychobiology.

Post-traumatic epilepsy in children requiring inpatient rehabilitation following head injury

OBJECTIVE

To study the prevalence of, and identify possible risk factors for, the development of post-traumatic epilepsy in a cohort of children with severe head injury treated in an inpatient rehabilitation unit.

METHODS

The hospital and community medical case notes of all children admitted prospectively to the unit and the records of the clinical EEG department over a seven year period were reviewed to identify those children who had developed late epilepsy after head injuries.

RESULTS

102 children received inpatient rehabilitation between 1 June 1991 and 28 February 1998. Follow up of these patients ranged from 18 months to over eight years. Nine patients (9%) developed post-traumatic epilepsy between eight months and over five years after the head injury. Three of the nine patients had experienced early tonic-clonic seizures in the first week after the injury. Other risk factors examined included the age of the patient, the cause of the head injury, initial Glasgow coma scale score, neuroimaging findings, and duration of ventilatory support. Only the presence of early seizures (p = 0.002) and possibly the Glasgow coma scale score (p = 0.043) were found to be specific risk factors for late late epilepsy.

CONCLUSIONS

Post-traumatic epilepsy appears to be uncommon, even in children with severe head injuries. Early seizures may indicate increased risk of developing late post-traumatic epilepsy in this study population.

The risks of epilepsy after traumatic brain injury

The aim of this study is to present the incidence of traumatic brain injury (TBI) and identify those characteristics of brain injuries that are associated with the development of seizures. We identified 5984 episodes of TBI (loss of consciousness, post-traumatic amnesia, or skull fracture) in Olmsted County, Minnesota, from 1935 to 1984. Of these, 4541 were followed for seizure. Injuries were classified as mild (loss of consciousness or amnesia less than 30 minutes), moderate (loss of consciousness 30 minutes to 1 day or a skull fracture), or severe (loss of consciousness of more than 1 day, subdural hematoma, or brain contusion). The incidence of TBI in the period from 1975 to 84 peaked at 800 per 100 000 in males aged 15-24. The relative risk of seizures was 1.5 (95 percent confidence interval 1.0-2.2) after mild injuries, but with no increase after 5 years; 2.9 (95 percent confidence interval 1.9-4.1) after moderate injuries; and 17.2 (95 percent confidence interval 12.3-23.6) after severe injuries. Significant risk factors were brain contusion with subdural hematoma, skull fracture, loss of consciousness or amnesia of 1 day or more, and age over 65 years. We conclude that TBI is a major public health problem and contributes to the occurrence of seizures and epilepsy.

Posttraumatic epilepsy risk factors: one-year prospective study after head injury

PURPOSE

Prospective evaluation of risk factors for posttraumatic epilepsy (PTE) by using clinical, EEG, and brain computed tomography (CT) data in four assessments from the head injury (HI) acute phase to 1 year later; and evaluation of the possible epileptogenic role of hemosiderin as shown by brain magnetic resonance imaging (MRI).

METHODS

Risk factors for PTE were evaluated by using Kaplan-Meier curves, log-rank test, and the Cox model in 137 consecutively enrolled adult inpatients. Percentage differences of patients with brain hyperintense and/or hemosiderin areas shown by MRI 1 year after HI were statistically evaluated by univariate tests considering two subgroups [e.g., patients with (PTE) and without (WLS) late seizures].

RESULTS

The PTE subgroup included 18 patients with at least two seizures between the second and twelfth months. Kaplan-Meier curves demonstrated that Glasgow Coma Scale low score, early seizures, and single brain CT lesions are PTE risk factors, as is the development of an EEG focus 1 month after HI. No significant percentage difference was found between PTE and WLS patients with hemosiderin spots shown by MRI 1 year after HI.

CONCLUSIONS

the Cox model indicates that, for HI patients with early seizures and brain CT single temporal or frontal lesions in the acute phase, the PTE risk is 8.58 and 3.43 times higher, respectively, than for those without. An EEG focus 1 month after HI is a risk factor 3.49 times higher than for patients without such EEG changes. One year after HI, a higher percentage of PTE than WLS patients had cortical MRI hyper-intense areas including hemosiderin.

Early and late posttraumatic seizures in traumatic brain injury rehabilitation patients: brain injury factors causing late seizures and influence of seizures on long-term outcome

PURPOSE

To demonstrate risk factors involved in the origin of late posttraumatic seizures (LPTSs) in civilian traumatic brain injury (TBI) rehabilitation patients and the occurrence of LPTSs in this population, as well as the time of the first late seizures, and influence of these seizures on functional and occupational long-term outcome.

METHODS

A consecutive sample of 490 patients (age range, 0.8-71 years) with TBI, and with postinjury problems in their education and employment, were followed up for > or =5 years from the time of injury in a rehabilitation and reemployment program. The study was carried out at the outpatient neurologic clinic of the Kauniala Hospital, which specializes in brain injuries in Finland and works in close cooperation with the Department of Clinical Neurosciences at the Helsinki University Central Hospital. Main outcome measures were functional outcome, as measured on the Glasgow Outcome Scale (GOS), and the capacity for employment at the end of follow-up. Outcomes were studied separately among patients with late seizures and for the nonseizure group.

RESULTS

Children age 7 years or younger at time of injury more often had early posttraumatic seizures (EPTSs), than did adolescents or adults. The time elapsed between brain injury and the first late seizure also was longer in older age groups. EPTSs and depressed skull fracture had a statistically significant relation to the origin of LPTSs. Permanent posttraumatic neurologic deficit, linear skull fracture, and permanent local brain lesion documented on a computed tomography (CT) scan appeared clinically important as risk factors. Late seizures did worsen the functional outcome but had no significant influence on reemployment at the end of follow-up.

CONCLUSIONS

Young children are more prone to early seizures, and adolescents and adults, to late seizures. The main risk factors for LPTSs are early seizures and depressed skull fracture. Severity of brain injury, as measured by a low GCS score, prolonged unconsciousness, and posttraumatic amnesia (PTA) without local brain lesion, should not be considered risk factor for LPTSs. Thorough follow-up of patients with TBI with seizures and adequate antiepileptic therapy may help attain rehabilitation goals and reemployment.

Post-traumatic epilepsy: its complications and impact on occupational rehabilitation--an epidemiological study from India

The objective of this study was to assess the prevalence of seizure disorder, neuropsychiatric disorders and reproductive outcome of employees with post-traumatic epilepsy (PTE) and their effect on occupational rehabilitation. A case-comparison group study design was used to compare 30 subjects with PTE with (1) 129 non-PTE and (2) 55 non-PTE matched control employees. The 55 non-PTE matched controls were selected from the 129 non-PTE employees on the basis of age, age at onset of seizure, age at marriage and length of employment. The PTE group had a lower fertility rate than the controls and more neuropsychiatric disorders and seizure disability. PTE employees were more occupationally rehabilitated than non-PTE employees (p = 0.033). Of the 30 PTE subjects, thirteen who were rehabilitated by placement had more seizure disability (p = 0.007) and a higher fertility rate (p = 0.018). High prevalence of seizure disability and increased fertility rate among the placed PTE employees suggested that there might be some association between severity of seizures and increased production of live offspring and work placement. Work suitability or placement should not be judged on clinical assessment only but psychosocial seizure assessment, disability evaluation and other psychometric tests which are of equal importance.

Preventing post-traumatic epilepsy after brain injury: weighing the costs and benefits of anticonvulsant prophylaxis

If the primary goal in the treatment of traumatic brain injury is the minimization of post-injury morbidity, treatment strategies that effectively prevent the development of post-traumatic epilepsy and have a beneficial (or at least neutral) impact on functional recovery are necessary. Here, Theresa Hernandez discusses the degree to which the current post-injury practice of anticonvulsant prophylaxis satisfies each of these criteria.

[Cooperative multicentric study on posttraumatic epilepsy]

A multicenter cooperative study was conducted to investigate factors influencing posttraumatic epilepsy (PTE) and to evaluate the prophylactic effect of anticonvulsants. A retrospective study of 102 PTE patients revealed the following typical clinical features: occurrence in young males, traffic accidents, contusion and/or cerebral hematoma. The latent period after the injury was longer in children. The percentage of EEG paroxysmal activity gradually increased as the generalized abnormality diminished. A retrospective-prospective study of 1998 patients who suffered a head injury between 1984 and 1988 was conducted till 1994. During the follow-up period, 62 patients (3.1%) developed PTE. The drop-out cases were excluded, and the 154 cases followed at least two years were analyzed. Statistical analysis of differences between patients with and without PTE suggested following factors: young, immediate early epilepsy (within 24 hours after injury; IMEE) and early epilepsy (within one week after injury). The risk with the highest relative risk rate was early epilepsy. Multiple regression analysis revealed that three factors, IMEE, early epilepsy and young age, contributed to the prediction of PTE. There was no significant difference in the percentage of patients having PTE in the group treated with anticonvulsants and the untreated group. Anticonvulsant treatment after head injury was unlikely to have a prophylactic effect on the development of PTE.

Causes, prevention, and treatment of post-traumatic epilepsy

Post-traumatic seizures often occur after severe head injury. Acutely, these seizures complicate management of the head-injured patient by increasing intracranial pressure and causing postictal decreases in level of consciousness. In the long term, epilepsy can have a negative effect on the patient's functioning and integration into society. The more severe the head injury, the more likely that post-traumatic seizures will occur. The risk of late seizures exceeds 30% for patients with penetrating head injury, intracerebral hematoma, subdural hematoma, depressed skull fracture, or seizure within the first week after injury. Late post-traumatic seizures are treated the same as any epileptic seizures of the same type. Phenytoin and carbamazepine are effective in preventing seizures in the first week after head injury, but are not effective in preventing late seizures. Both additional antiepileptic drugs and neuroprotective agents that may lessen the damage that leads to seizures are being investigated to determine if they are effective in preventing the occurrence of post-traumatic epilepsy.

Family history of seizures in posttraumatic and alcohol-associated seizure disorders

The potential role of genetic factors in the etiology of posttraumatic and alcohol-associated seizures was studied in 289 male patients with recurrent seizures and in 174 individuals who had never experienced a seizure. The incidence of seizures in first-degree relatives of probands was compared with that in relatives of unaffected individuals. Relatives of patients with alcohol-associated seizures had a rate ratio of 2.45 [95% confidence interval (CI) 1.41-4.25], whereas no excess incidence was noted among relatives of posttraumatic epilepsy patients (rate ratio 1.20, 0.64-2.25 CI). Relatives of probands with both antecedents showed an intermediate rate ratio of 1.72 (0.92-3.20 CI). Among probands with alcohol-associated seizures, the rate ratio of 2.05 for patients with alcohol-related seizures (i.e., spontaneously occurring seizures in association with chronic alcohol abuse) was slightly higher than that of 1.85 for probands with alcohol withdrawal seizures. Trauma severity had a slight impact on the incidence of affected relatives; patients with severe head injuries had a rate ratio of 0.73 and probands with milder trauma had a rate ratio of 0.99. The results indicate a limited, if any, role of genetic predisposition in development of posttraumatic seizures. Alcohol-related seizures, however, showed familial aggregation of unprovoked seizures, suggesting an involvement of genetic factors in the origin of such seizures.

[Epidemiologic study of post-traumatic epilepsy on the Island of Majorca]

The epidemiological study of post-traumatic epilepsy after 10 years of follow-up on the island of Mallorca is reported. The double prospective and retrospective method was used for patient selection. Prospectively, 23,082 isolated head injuries were studied in the Hospital of Son Dureta in Palma de Mallorca between the years 1980 to 1988. Retrospectively, 663 epileptics proceeding from different data bases of different centers were studied. Two hundred and twelve post-traumatic epilepsies of certain etiology were identified. Results are discussed with regard to age, sex and latency time found. Special emphasis is made in that benign cerebral concussion is not causing seizures. A prevalence of 4% of post traumatic epilepsy is found in the population of risk head injuries, and post-traumatic epilepsy represents 7% of the total of the casuist of epileptic patients.

Posttraumatic epilepsy. Incidence and prophylaxis

A detailed review, based on the literature and the author's own series, is given of the incidence of both early and late epilepsy following head injury related to age, severity and other specific features of the injury and clinical sequelae. Use of prophylactic anti-convulsant therapy, following head injury, remains controversial despite positive results of animal experiments. Hence, the author recommends that antiepileptic medication should be restricted to patients who have had at least two epileptic fits during the first two years after injury.

[Epileptic syndrome in craniocerebral injuries]

Fifty clinical cases in which epileptic seizures appeared after craniocerebral injury were studied. Severe craniocerebral injury prevailed (in 66%). In 72% of cases the seizures occurred in the first year following the injury, in 52% of these in periods of 2 to 12 months. Dependence of the structure of the seizures on the predominant affection of the right or left cerebral hemisphere is shown.

Epilepsy after penetrating head injury. I. Clinical correlates: a report of the Vietnam Head Injury Study

Of 421 veterans who had penetrating brain wounds in Vietnam 15 years ago, 53% had posttraumatic epilepsy, and one-half of those still had seizures 15 years after injury. The relative risk of developing epilepsy dropped from about 580 times higher than the general age-matched population in the first year to 25 times higher after 10 years. Patients with focal neurologic signs or large lesions had increased risk of epilepsy, and site of the lesion may have been more important than size in determining occurrence. Family history of epilepsy or preinjury intelligence had no effect on seizure occurrence. Seizure frequency in the first year predicted future severity of seizures. Phenytoin therapy in the first year after injury did not prevent later seizures.

Posttraumatic seizures: an assessment of the epidemiologic literature

Confusion about the risk of seizures following head trauma might in part reflect methodologic limitations of reported studies. This epidemiologic review emphasizes four methodologic issues: selection of cases, selection of controls, definition and ascertain of seizures, and definition, of seizures, and definition, classification, and ascertainment of trauma. Although the focus of this review is a set of reports of civilian injuries, the relevance of war studies to civilian injuries is also discussed.

[Epilepsy in later life: seizures persisting after the age of 60]

In a group of 657 epileptic patients there were 51 presenting with fits even after having reached the age of 60. The onset of seizures dated back to the first 20 years in 15 patients between 20 and 40 years in 15 and between 40 and 60 years in 21. In 67% of the cases it was possible to determine the cause of seizures. The aetiology was unevenly distributed within each group. In the first group (up to 20 years) the P.G.E. forms prevail. In the second (up to 40 years) post traumatic epilepsy and inflammatory processes were predominant, while in the third (up to 60 years) vascular and tumoral pathology seem to be prevalent. 43% of the patients showed paroxysmal abnormalities in the EEG and these were still present even after to age of 60 years in more than fifty per cent. After the age of 60 we found no case of benign epilepsy amenable to complete recovery. Patients older than 60 present epilepsies of mild severity. In symptomatic epilepsies the lesional factors were not subject to evolution and the epileptogenic focuses were stable and persistent. In partial epilepsy there were more cases of complex symptomatology (86%) than cases of elementary symptomatology (14%) The evolution of seizures in old age is considered together with the importance of all factors influencing recurrency.

Early post traumatic seizures in adults. Study of 84 cases

In a series of 2.980 brain-injured patients, 84 (2.8%) showed epileptic seizures. Epilepsy occurred with a higher incidence rate in operated patients (11.6%) than in non operated ones (1.2%). Seizures appeared within the first week since trauma in 91% of the cases. They have been single in 48%, recurring in 34%, with figures of status epilepticus in 16% partial in 61%, and GM in 33%. Prognosis quoad vitam of early epilepsy seems to be favourable, however, in severely brain-injured patients, seizures occur more frequently and may determine a worsening of the clinical picture even if they are not responsible for the death.

Epilepsy, a product of trauma in our time

Using data obtained by the National Center for Health Statistics through household interviews, an estimate of 8,100,000 cases of head injury was determined for the civilian population of the United States in 1974. Excluding contusions and lacerations of the scalp, face, and neck; there remained 1,900,000 with concussion, skull fractures, intracranial hemorrhage, cerebral laceration, or other intracranial injury. Extrapolating from the military experience with craniocerebral trauma admittedly a rough approximation, it is estimated that in 30% of this latter group one more seizures will develop. Both severity of the injury and the predisposition of the injured are thought to play a part in the occurrence of seizures, with the predisposition playing the dominant role in the persistence of seizures. The following gradation of posttraumatic epilepsy is predicted for the 1,900,000 with the greater implication of brain damage: 1,340,000 will never have a seizure; 560,000 will develop one or more attacks, most of which will begin in 1974, 1975, or 1976. In 280,000 of these, the attacks will be transient and of little consequence. In an equal number, the attacks will require medical attention, and in some 140,000 the seizures will be intractable to therapy. This latter group represents 7% of the 1,900,000 cases. Attention is directed to the practical problems in the control of carniocerebral trauma and of posttraumatic epilepsy.