Recently I have seen a few patients with post traumatic epilepsy and hence I decided it might be appropriate to talk about the same in more depth.
Before we begin though I want to wish all the readers of my blog from around the world a very Happy and Healthy New Year 2012. May it bring you not just a healthy brain but also a healthy mind.
Ok now to the topic at hand. Just what do neurologists and neurosurgeons mean when they say you have post traumatic epilepsy? As the name suggests post traumatic epilepsy (PTE) refers to epilepsy/seizures starting after a patient sustains head trauma. Let me explain with an example. Let us assume John is involved in an motor vehicle accident. While driving down the FDR drive late one night he falls asleep behind the wheel of his car. The roads are icy! John’s car spins out of control, jumps the curb and hits an embankment. John who is not wearing a seat belt gets thrown out of the car striking his head first on the windscreen and then on the unyielding asphalt concrete. A passerby witnesses the accident and calls 911. EMS are on the screen within minutes but John is not moving. His neck is stabilized in a hard collar and he is rushed to the nearest hospital. Glasgow coma scale (GCS) on arrival is documented to be 5. John is not responding to verbal commands and is rushed to the CT scanner for a stat head CT. CTscan shows all is not well. John has sustained significant head trauma. He has a fracture of the right temporal bone and an underlying epidural hematoma. There are bilateral frontotemporal contusions which are increasing in size. In addition there is diffuse subarachnoid hemorrhage. The epidural hematoma is evacuated that night itself by the neurosurgeon on call. It is decided that at present the frontal lobe contusions be closely observed. John is transferred to the neurological ICU where he is further stabilized. A close watch is kept on the intracranial pressure.
Fast forward 3 weeks.
After a rocky course in the neurological ICU, John makes a remarkable recovery taking the extent of his head injury into consideration. He is discharged from the hospital to a rehab facility skilled in traumatic brain injuries (TBI). In the rehab facility John makes a slow but steady progress. It is 12 noon and John as usual is working with his physical therapist. He suddenly stops what he is doing. Utters a loud guttural sound, falls down to the floor with his eyes rolled up. The therapist notes that he stiffens up for a few seconds and then starts to shake while frothing at the mouth. The whole seizure lasts for about 2 minutes and then subsides on its own. Post seizure John is confused and disoriented but slowly returns to his baseline in about 40 minutes. An appointment is made for John to see Dr. Feelgood a neurologist in the nearby community hospital.
Dr. Feelgood takes a detailed history and then examines John. You have post traumatic epilepsy John, he says and recommends that John consider starting anticonvulsant therapy without further delay.
The scenario I describe above is unfortunately not uncommon in patients who sustain significant head trauma. In fact head trauma is one of the leading causes of epilepsy in men and women below the age of 40 around the world. The human brain is well protected by an extremely rigid skull and so the trauma has to be significant to cause brain damage and resulting PTE.
MINOR BUMPS AND BRUISES TO THE HEAD DO NOT LEAD TO POST TRAUMATIC EPILEPSY. Post traumatic epilepsy is thus very rarely reported after closed head injuries aka concussions such as those sustained on the sport fields(please read my post about concussions either here or on my website http://braindiseases.info). On the other hand PTE is particularly common after penetrating head injuries such as gun shot wounds to the head or when the skull bone is fractured (especially depressed skull fracture where the bone fragment presses on the underlying brain) or when there is significant intracranial bleeding (remember what John’s CT scan showed: blood in the epidural space and hemorrhage into both the frontal and temporal lobes).
Seizures can occur at any time after a significant head injury. The patient may start having seizures immediately after sustaining the head injury. This is called early post traumatic epilepsy and at times this has a more favorable prognosis. After the blood in the brain goes away and the swelling/pressure in the brain subsides, the seizures may also stop spontaneously. Hence these patients may not need to remain on an anticonvulsant medication for a long time. Seizures though have been reported as far out as 5 years after the head injury. This is called late post traumatic epilepsy and these patients usually need to take anticonvulsant medication for a prolonged duration, at times even lifelong.
Depending on the extent of head trauma, seizures may be easy or hard to control in these brain trauma patients. They are usually prescribed anticonvulsant therapy and seizure control is then closely monitored. If seizures persist then a second or third anticonvulsant may be indicated.
Dr. Feelgood started John on a seizure medication by the name of levetiracetam. He advised John to follow up with him after 3 months. On the 3 month follow up visit, John walked into Dr. Feelgood’s office unaided and with a broad smile on his face.
I feel good, Dr Feelgood he said.
I’m wondering if a bang on the right side of the head (collision with a large dog) which caused a black eye and bruise down the side of the face could cause seizure activity after 3 months. When worked up previously for something else the EEG was normal. Three months later the EEG showed seizure activity with no apparent seizures. The neurologist said that it could not be caused by the dog collision.
I started having partial seizures that eventualy led to a tonic–clonic seizure (formerly known as a grand mal seizure). This all happened within 3 months after a brain biopsy to get a sample of 1 of the 12 tumors(leisons) that were seen on an MRI presentation. Later on I was diagnosed with Multiple Sclerosis, albeit with leisons that were atypical in regards to location of them in my brain(it’s a long story). But the thing I find interesting about your post here is “head trauma leaves behind a seizure disorder”. I know that seizures can be a symptom of Multiple Sclerosis, but…Only in 2-4% of patients diagnosed with Multiple Sclerosis. If you any thoughts about this, I would be interested to hear them. Thanks so much any input you may have!
My 15 year old daughter hit the back of her head in a basketball game had grade 3 concussion 2 days later developed seizures. This started 12/5/2012 she was started on tegretol 400 twice a day. The seizures over the last few months have become more frequent an it is now 3/17/12 and she takes 400 tegretol 500 keppra 100 lamictal in the morning 600 tegretol 500 keppra at night. Her MRI in December looked good could this concussion still be the cause of the seizures? Should we get another MRI? We are currently waiting for video monitoring are there other things we should be getting done. I feel that the drs just keep throwing more meds at her and she is on lots of meds for a small 15 year old.
Dear Lisa,
thank you for writing in to me about your daughter. When we talk about post traumatic epilepsy, usually it has to be severe head trauma that precipitates the seizure disorder. What do I mean by severe head trauma you may ask. Well any head trauma which leads to a prolonged loss of consciousness is usually classified as severe. Penetrating head injuries, injuries accompanied by a skull fracture especially if the fracture is depressed are severe. Minor “bumps” and “bruises” to the head (minor closed head trauma) do not cause seizures and do not make pre-existing seizure disorder worse.
Personal Regards,
Nitin Sethi, MD