脑外伤癫痫课件.ppt
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- 脑外伤 癫痫 课件
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1、Posttraumatic Seizure(PTS)Risk and Management in TBI:ObjectivesGuidelines for PTS prophylaxis:AANS,AAPMRPredict PTS risk based on clinical presentationAnalyze treatment strategies for individuals with late PTS from case studyPosttraumatic Seizure(PTS)definitionTemporary brain dysfunction with excess
2、ive,hypersynchronous discharge of cortical neurons Immediate:first 24 hours post injury Early PTS:first 7 days Late PTS:after one week EpilepsyRecurrent unprovoked seizures TBI accounts for 5-20%symptomatic epilepsy in general population Early PTS-3-15%adults,10-15%children;17-33%develop late PTS,ad
3、ults children Late PTS-86%recurrent seizures in 2 yrs(Haltiner et al,2019)Consumer Feedback early 1990s:Anticonvulsants(AED)No Standard of care:AEDs continued indefinitely MDs reluctant to discontinue medications,especially prescribed by another MD Memory problems and compliance Drug side effects:at
4、axia,rashes,periodontal care,hair growth or loss,slowed thinking Cost of medications,laboratory testsAANS(2019,2000)and AAPM&R(2019)Practice Parameters Recognize effects of AEDs on recovery,compliance Lack of efficacy in prevention of late PTS Option:Phenytoin,carbamazepine may prevent early PTS in
5、high risk TBI;early PTS treatment does not prevent late PTS or improve outcome Standard:Prophylactic anticonvulsants not recommended for prevention of late PTSTraditional Risk Factors for late PTS Penetrating shrapnel injuries,military:53%over 15 years(Salazar,1985)Coma 3 weeks:25%(Guidice,1987)Earl
6、y PTS-late PTS:17-33%,age related in some studies Intracranial hematoma:Epidural,22%;subdural or intracerebral,45%(Jennett,1975)Multi-center study rationale What is natural history late PTS with new guidelines?CT scan findings not incorporated into risk factor profile in previous studies Civilian gu
7、nshot wounds may be different from military shrapnel wounds-seizure risk Follow-up mechanisms already in place through TBI Model Systems grants:sufficient numbersHypotheses:multi-center,prospective study late PTS by 2 years 1st year incidence 2nd year GCS injury severity will predict late PTS Intrac
8、ranial lesions by CT scan predict late PTS Dural penetration predict late PTSProspective enrollment of severe TBI Trauma centers:Denver,Richmond,Detroit,San Jose 16 yo,not pregnant,no previous seizure,stroke,tumor,intracranial surgery;AEDs 1 mo post TBI CT lesions during first week post TBI SAH or i
9、ntraventricular hemorrhage cerebral contusion epidural or subdural hematoma depressed skull fracture with dural penetration OR Best GCS in first 24 hours 80%Confirmed events categorized by neurologist generalized or focal-generalized seizure focal seizure Statistics:survival analysis,relative risk c
10、alculationsTime course and quality of late posttraumatic seizures 647 enrolled over 4 years 14%late PTS by 2 years 40%occurred 8-30 days 63%by 6 months 80%by 12 months 93%by 18 months 79%generalized;21%focalEarly PTS(7days post injury)and late PTS 21/647(3%)had early seizures Next seizure occurred 6
11、 months if early PTSInitial GCS and late PTS GCS 3-8:17%relative risk GCS 9-12:24%relative risk GCS 13-15:8%relative riskSeverity of injury as measured by GCS did not correlate with late PTSGCS not particularly helpful in predicting seizure riskMidline shift and cisternal compression on CT scan and
12、late PTS Cisterns open,1 mm shift:10%Cisterns open,1-5 mm shift:15%Cisterns compressed,5 mm shift:26%Degree of cerebral compression is associated with late PTS,especially 5 mm midline shiftCortical Contusions:Relative risk of late PTS No contusion:6%Single contusion:8%Bilateral or multiple contusion
13、s:25%bifrontal:26%bitemporal:31%biparietal:66%Bilateral contusions amongst highest risk factors for late PTSSubcortical contusions and relative risk for late PTS No subcortical contusion:13%Single subcortical contusion:16%Multiple subcortical contusions:33%High association of multiple subcortical co
14、ntusions and late PTS:probably marker for severe TBI.Penetrating Injuries and late PTS No penetrating bone,metal fragments:14%Bone fragments only:0%Bone and metal fragments:63%Metal fragments(bullets)have a very high association with late PTS and are comparable to shrapnel injuries.Bone fragments al
15、one have minimal increased risk.Mass lesions and relative risk of late PTS Epidural hematoma(EDH)no EDH:14%EDH,no evacuation:8%EDH with evacuation:19%Subdural hematoma(SDH)no SDH:10%SDH,no evacuation:15%SDH with evacuation:28%Neurosurgical procedures and relative risk of late PTS 1 evacuation of int
16、racerebral hematoma:75%1 operation:37%;1 operation:15%;none:11%Ventriculostomy:25%;no ventriculostomy:13%More severe injuries require more neurosurgical procedures;those individuals have higher risk of late PTSLength of phenytoin prophylaxis and relative risk of late PTSDays DPH%Relative risk None7%
17、1-7 days12%8-14 days17%15-30 days30%*p=.0002Probably a marker for more severe injuryStudy Limitations Dural penetration“n”too small(26/647)Prolonged or late anticonvulsant use:sicker patients had to be dropped Self report of symptoms:bias to seizures that generalize as these are more recognizable Co
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