Attending Physician Memorial Healthcare System Hollywood, Florida, United States
Case Diagnosis: Late-onset seizures in TBI patient causing repeat TBI
Case Description: A 19 year-old male with past medical history of prior TBI and blunt force cardiopulmonary trauma due to motorcycle accident complicated by coronary artery dissection requiring ECMO, presented to the emergency department due to new head trauma. Patient was riding a bicycle without a helmet when he lost consciousness, fell from his bike, and hit his head. Imaging demonstrated an acute traumatic extra-axial hemorrhage along the anterior left paramedian frontal lobe as well as chronic 16mm mixed density subdural hematoma overlying the right frontal convexity causing mass effect with 4 mm midline shift. Patient’s mother reported the patient had been experiencing episodes of staring into space for several seconds before returning to baseline. EEG demonstrated the presence of focal epileptogenic abnormalities and focal slowing over the right frontocentral head region consistent with right frontocentral seizure onset. Patient was started on Keppra for seizure prophylaxis, and underwent middle meningeal artery embolization.
Discussions: Post-traumatic seizures (PTS) and post-traumatic epilepsy (PTE) are possible complications after traumatic brain injury (TBI). Seizures can be immediate, early, or late-onset, with immediate seizures occurring within the first 24 hours after TBI, early seizures between 24 hours to 7 days after TBI, and late seizures occurring greater than 7 days after TBI. Treatment includes anti-epileptic medications such as levetiracetam and valproic acid. Phenytoin is another option. While it reduces the risk of early seizures, it is not useful for late seizures. Treatment with antiepileptic medications for PTE is typically maintained for 2 years before attempting to wean.
Conclusions: PTS/PTE worsens functional outcomes in TBI patients and can predispose patients to further injuries. Prevention of post-traumatic seizures is imperative in the immediate and acute time frame. Patients who develop late PTS/PTE must be appropriately managed with long-term antiepileptic medications and neurology follow-up.
