September 2014
Ellen J. S. Riry
2008-83-023
Pembimbing:
dr. Semuel Wagiu, Sp.S, M.Ked
Dibawakan dalam rangka tugas kepaniteraan klinik
di Bagian Neurologi Faktultas Kedokteran
Universitas Pattimura
Ambon
ABSTRACT
Posttraumatic epilepsy (PTE) : major long-term
complication of traumatic brain injury (TBI) within 5
years
Risk :
53% penetrating TBI
10-25% combat-associated closed-head trauma with positive brain
imaging
5% moderately severe closed-head injury without imaging finding
DEFINITION
INTRODUCTION
Definition of Posttraumatic Epilepsy
Traditional definition of epilepsy : 2 or more unprovoked
seizures after a head injury >1 week after the head
injury
86% patients with 1 unprovoked posttraumatic seizure
experienced a 2nd seizure within 2 years
Patient with 1 unprovoked posttraumatic seizure
extremely high risk of developing PTE
Other definition: 1 or more unprovoked seizure late head
injury need an early treatment
Seizures that occur within the first 7 days after TBI are
defined as provoked seizures
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POSTTRAUMATIC EPILEPSY IN
CONTEXT OF OIF/OEF
Medical Cost of Posttraumatic Epilepsy
Max latent period of PTE : 20 years after TBI
Uncontrolled seizures can be fatal :
Seizures seizures
Aspirate during seizures pneumonia and
damage to the airways and lungs
Disrupt blood pressure and heart control sudden
death
Disrupt respiratory and blood temperature control
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Nonconvulsive Seizures
partial seizure manifest with subtle behavioral
alterations mistaken for apathy catatonia or PTSD
presentation of a complex partial seizure could be
featureless
for early detection : every clinican who treats patients
with TBI is aware of this condition.
EEG is often needed to establish a diagnosis of nonconvulsive seizure
the most recent report : identified a little over 32.000
injuries and around 5.500 individuals with TBI
the number of PTE cases will increase if hostilities
continue
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Table 1
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Table 2
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POSTTRAUMATIC EPILEPSY
TREATMENT
Introduction
clinicians routinely use new and effective
AEDs with different mechanisms of actions
other option : sugical evaluation Epilepsy
Monitoring Unit (EMU)
specialists consider resection surgery to
remove the seizure focus to be standard of
care in patients with epilepsy that is refractory
to medical treatment alone.
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Prevention
a number of published uncontrolled,
unblinded observational studies have
investigated the effect of AEDs in preventing
PTE:
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Epileptogenesis
Basic Aspects
epileptogeneis describes the molecular, cellular,
and network processes
far from fully understood
have emerged based on ressearch using various
results from animal models of epilepsy
An injury to the superficial layers of GABAergic
neurons in TBI could tilt the dedicated balance
between the excitatory and inhibitory neurons
toward hyperexcitability
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Onset
theory : 1 critical issue in PTE prophylaxis is
initiation of antiepileptogenic therapy before the
epileptogenesis process starts, or at least before it
escalates to an irreversible stage
Principle : TBI could set the process of
epileptogenesis inmotion, and many other
accessory factors will also determine whether
epileptogeneis could complete its course of
developing PTE
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Early Treatment
AED prophylaxis effective in controlling the early
provoked seizure AED up to 1 week after TBI :
advisable
initiated as early as possible
longterm AED after TBI : not recommended
the possibility that some AEDs might have a negative
effect on the recovery of brain function after TBI
???
25
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Pharmacotherapy
PTE in patient (+) initiate AED therapy
following the general guidelines used for other
types of acquired epilepsy.
monotherapy or polytherapy (at least 2 AEDs
of different pharmacological mechanisms)
follow the general treatment principles
using the least amount of AED
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CONCLUSIONS
PTE might represent a large, complex
problem that should not be ignored
any plans to address the problem should
be coordinated with existing polytrauma
and TBI programs
experts are available within the VA to
evaluate the problem and design efficient,
proactive solutions
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THANK YOU.
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