Early posttraumatic seizures in pediatric traumatic brain injury: a multicenter analysis

OBJECTIVE Early posttraumatic seizures (EPTSs) in children after traumatic brain injury (TBI) increase metabolic stress on the injured brain. The authors sought to study the demographic and radiographic predictors for EPTS, and to investigate the association between EPTS and death, and between EPTS and poor functional outcomes among children with moderate to severe TBI in Asia. METHODS A secondary analysis of a retrospective TBI cohort among participating centers of the Pediatric Acute & Critical Care Medicine Asian Network was performed. Children < 16 years of age with a Glasgow Coma Scale (GCS) score ≤ 13 who were admitted to pediatric intensive care units between January 2014 and October 2017 were included. Logistic regression analysis was performed to study risk factors for EPTS and to investigate the association between EPTS and death, and between EPTS and poor functional outcomes. Poor functional outcomes were defined as moderate disability, severe disability, and coma as defined by the Pediatric Cerebral Performance Category scale. RESULTS Overall, 313 children were analyzed, with a median age of 4.3 years (IQR 1.8–8.9 years); 162 children (51.8%) had severe TBI (GCS score < 8), and 76 children (24.3%) had EPTS. After adjusting for age, sex, and the presence of nonaccidental trauma (NAT), only younger age was significantly associated with EPTS (adjusted odds ratio [aOR] 0.85, 95% CI 0.78–0.92; p < 0.001). Forty-nine children (15.6%) in the cohort died, and 87 (32.9%) of the 264 surviving patients had poor functional outcomes. EPTS did not increase the risk of death. After adjusting for age, sex, TBI due to NAT, multiple traumas, and a GCS score < 8, the presence of EPTS was associated with poor functional outcomes (aOR 2.08, 95% CI 1.05–4.10; p = 0.036). CONCLUSIONS EPTSs were common among children with moderate to severe TBI in Asia and were associated with poor functional outcomes among children who survived TBI.

Neuroinflammation and Neuronal Loss in the Hippocampus Are Associated with Immediate Posttraumatic Seizures and Corticosterone Elevation in Rats

Hippocampal damage after traumatic brain injury (TBI) is associated with late posttraumatic conditions, such as depression, cognitive decline and epilepsy. Mechanisms of selective hippocampal damage after TBI are not well understood. In this study, using rat TBI model (lateral fluid percussion cortical injury), we assessed potential association of immediate posttraumatic seizures and changes in corticosterone (CS) levels with neuroinflammation and neuronal cell loss in the hippocampus. Indices of distant hippocampal damage (neurodegeneration and neuroinflammation) were assessed using histological analysis (Nissl staining, Iba-1 immunohistochemical staining) and ELISA (IL-1β and CS) 1, 3, 7 and 14 days after TBI or sham operation in male Wistar rats (n = 146). IL-1β was elevated only in the ipsilateral hippocampus on day 1 after trauma. CS peak was detected on day 3 in blood, the ipsilateral and contralateral hippocampus. Neuronal cell loss in the hippocampus was demonstrated bilaterally; in the ipsilateral hippocampus it started earlier than in the contralateral. Microglial activation was evident in the hippocampus bilaterally on day 7 after TBI. The duration of immediate seizures correlated with CS elevation, levels of IL-1β and neuronal loss in the hippocampus. The data suggest potential association of immediate post-traumatic seizures with CS-dependent neuroinflammation-mediated distant hippocampal damage.

Penetrating Brain Injuries

Penetrating brain injury (PBI) may result from missiles (high velocity) or non-missiles (low velocity), with the latter having a better prognosis and more frequently resulting in favorable patient outcomes. Certain risks, complications, and management principles are common across all types of PBI. These include the potential for the development of mass lesions, cerebral edema, and neurological deterioration, as well as a high risk of concomitant cerebrovascular injury, CSF leak, infection, and posttraumatic seizures. In most cases, urgent surgical treatment is warranted to mitigate these associated risks. This chapter will focus primarily on the assessment, diagnostic workup, decision making, and management of non-missile and low-velocity PBI.

Seizures in the Setting of Trauma

This chapter on seizures in the setting of trauma reviews the risk factors for seizures after traumatic brain injury (TBI), their medical prophylaxis, and their management using a case study to illustrate salient points. Differentiation of early and late posttraumatic seizures is discussed. Pathogenesis, incidence, and risk factors for early and late posttraumatic seizures are reviewed, as is posttraumatic epilepsy. Appropriate prophylactic antiepileptic drugs (AEDs) are discussed, as well as the management of seizures and status epilepticus in the setting of TBI. Prognosis and anticipated outcomes are considered.

Nationwide incidence and risk factors for posttraumatic seizures in children with traumatic brain injury

OBJECTIVEPosttraumatic seizures (PTSs) are the most common complication following a traumatic brain injury (TBI) and may lead to posttraumatic epilepsy. PTS is well described in the adult literature but has not been studied extensively in children. Here, the authors utilized the largest nationwide registry of pediatric hospitalizations to report the national incidence, risk factors, and outcomes associated with PTS in pediatric TBI.METHODSThe authors queried the Kids’ Inpatient Database (KID) using ICD-9-CM codes to identify all patients (age < 21 years) who had a primary diagnosis of TBI (850.xx–854.xx) and a secondary diagnosis of PTS (780.33, 780.39). Parameters of interest included patient demographics, preexisting comorbidities, hospital characteristics, nature of injury (open/closed), injury type (concussion, laceration/contusion, subarachnoid hemorrhage, subdural hematoma, or epidural hematoma), loss of consciousness (LOC), surgical management (Clinical Classification Software code 1 or 2), discharge disposition, in-hospital complications, and in-hospital mortality. The authors utilized the IBM SPSS statistical package (version 24) for univariate comparisons, as well as the identification of independent risk factors for PTS in multivariable analysis (alpha set at < 0.05).RESULTSThe rate of PTS was 6.9% among 124,444 unique patients hospitalized for TBI. The utilization rate of continuous electroencephalography (cEEG) was 0.3% and increased between 2003 (0.1%) and 2012 (0.7%). The most common etiologies of TBI were motor vehicle accident (n = 50,615), accidental fall (n = 30,847), and blunt trauma (n = 13,831). However, the groups with the highest rate of PTS were shaken infant syndrome (41.4%), accidental falls (8.1%), and cycling accidents (7.4%). In multivariable analysis, risk factors for PTS included age 0–5 years (compared with 6–10, 11–15, and 16–20 years), African American race (OR 1.4), ≥ 3 preexisting comorbidities (OR 4.0), shaken infant syndrome (OR 4.4), subdural hematoma (OR 1.6), closed-type injury (OR 2.3), brief LOC (OR 1.4), moderate LOC (OR 1.5), and prolonged LOC with baseline return (OR 1.8). Surgically managed patients were more likely to experience PTS (OR 1.5) unless they were treated within 24 hours of admission (OR 0.8). PTS was associated with an increased likelihood of in-hospital complications (OR 1.7) and adverse (nonroutine) discharge disposition (OR 1.2), but not in-hospital mortality (OR 0.5). The overall utilization rate of cEEG was 1.3% in PTS patients compared with 0.2% in patients without PTS. Continuous EEG monitoring was associated with higher rates of diagnosed PTS (35.4% vs 6.8%; OR 4.9, p < 0.001).CONCLUSIONSPTS is common in children with TBI and is associated with adverse outcomes. Independent risk factors for PTS include younger age (< 5 years), African American race, increased preexisting comorbidity, prolonged LOC, and injury pattern involving cortical exposure to blood products. However, patients who undergo urgent surgical evacuation are less likely to develop PTS.