Seizures epilepsy associated with tbi
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SEIZURES & EPILEPSY Associated with TBI. Tracey A. Milligan, MD Director of Epilepsy, Faulkner Hospital Associate Neurologist, BWH Assistant Professor Harvard Medical School. No disclosures. What do you want to know?. Outline. Definitions and epidemiology Manifestations of seizures

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Seizures epilepsy associated with tbi


Tracey A. Milligan, MD

Director of Epilepsy, Faulkner Hospital

Associate Neurologist, BWH

Assistant Professor

Harvard Medical School

Seizures epilepsy associated with tbi

  • No disclosures

What do you want to know

What do you want to know?



  • Definitions and epidemiology

  • Manifestations of seizures

  • Diagnosis

  • Treatment

  • Co-morbidities and quality of life

  • Special situations

Epilepsy case

Epilepsy Case

Team approach

Team Approach

  • Epileptologist (neurologist with sub-specialty training in epilepsy)

  • Neuropsychologist

  • Neurosurgeon

  • Nurse

  • Psychiatrist

  • Social worker



  • What is a seizure?

    • A seizure is the result of a sudden disruption oforderly communication among nerve cells in the brain

    • Some lay terms that have been used to describe a seizure are a “fit,” “attack,” or “spell”

    • “Post-traumatic seizure”

  • What is epilepsy?

    • Epilepsy is not a single disease

    • Epilepsy is a group of related disorders characterized by recurrent spontaneous seizures

    • Two or more nonprovoked seizures

    • “Post-traumatic epilepsy”

What is epilepsy

What Is Epilepsy?

  • Epilepsy is one of the most common disorders of the nervous system

  • More than 3 million Americans of all ages areliving with epilepsy

    • Each year, approximately 200,000 Americans are diagnosed with epilepsy

  • Epilepsy can develop at any time of life and has many different causes

  • Epilepsy is the same as “seizure disorder”













Age Specific Incidence of Epilepsy

Incidence per 100,000 person-years


Hauser WA, et al. Epilepsia. 1993;34:453-468.

What causes epilepsy

What Causes Epilepsy?

  • Idiopathic—Unknown cause (may be genetic)

  • Symptomatic—epilepsy for which an underlying cause has been identified

    • Usually an injury or structural abnormality in the brain

  • Cryptogenic (probably symptomatic)—epilepsy for which an underlying cause has not been identified but is suspected

Trauma as a cause of epilepsy

Trauma as a Cause of Epilepsy

  • Risk of epilepsy is related to the severity of the trauma

  • Greatest risk is in the first 2 years after TBI

  • Most common cause of epilepsy in teens and young adults

Epilepsy facts

Epilepsy Facts

  • Epilepsy and its treatment produce a health-related quality of life similar to that associated with arthritis, heart problems, diabetes, and cancer

  • More than 1 of every 3 persons with epilepsy have depression

  • Overall mortality 2-3 times that of general population

  • Risk of sudden unexpected death is 24 – 40 times that in the general population and the cause of death in 2-18% of patients

Seizure categories

Seizure Categories

  • There are two types of seizures:

Partial seizures

Seizures that originate in one specific area on one side (hemisphere) of the brain

Generalized seizures

Seizures that originate inseveral areas on both sides (hemispheres) of the brain

Partial seizures

Partial Seizures

  • Simple partial seizures

    • Affect one specific part of the brain only, and do not cause a change in consciousness

  • Complex partial seizures

    • Affect a larger area of the brain and result in alteration or loss of consciousness

  • Secondarily generalized seizures

    • Begin as a partial seizure in one area of the brain and spread to affect the whole brain

Simple partial seizures

Simple Partial Seizures

  • Manifestation is dependent on area of brain

  • Temporal lobe seizures most common

    • Deja-vu

    • Anxiety

    • Out of body experience

Complex partial seizures

Complex Partial Seizures

  • Alteration in consciousness

  • Staring

  • Automatisms (Quasi-purposeful motor or verbal behaviors)

    • Verbal automatisms: simple vocalizations, stereotyped

    • Motor: oral (lip smacking, chewing, swallowing) and manual (picking, fumbling, patting)

  • Erroneously called “absence” or “petit mal” seizures by some

Absence seizure

Absence Seizure

  • Most common in children

  • Involves a brief disruption of consciousness

  • Previously referred to as a “petit mal” seizure

Between Seizures:

• Normal appearance

During Seizure:

• Vacant stare • Eyes roll upward• Lack of response

Generalized tonic clonic seizure

Generalized Tonic-Clonic Seizure

  • Occurs in all age groups

  • Involves complete loss of consciousness

  • Previously referred to as a “grand mal” seizure

Possible sequence of partial seizure

Possible sequence of partial seizure



Differential diagnosis of paroxysmal behavioral event

Differential Diagnosis of Paroxysmal Behavioral Event

  • Seizure

  • Syncope (convulsive)

  • Migraine

  • Cerebral ischemia (TIA)

  • Movement disorder

  • Sleep disorder

  • Metabolic disturbance

  • Psychiatric disturbance



  • History

  • Physical examination

  • Lab tests

  • EEG

  • MRI

Seizures epilepsy associated with tbi


  • Assess for epileptiform discharges

  • Help diagnose presence, type, and location of epilepsy

  • Negative EEG does not rule out epilepsy

  • Sleep deprived EEG more sensitive

  • EEG after spell or seizure is more sensitive (51% vs. 30%)

  • Extended monitoring: video EEG or ambulatory EEG can be helpful

Seizures epilepsy associated with tbi




  • After 1st seizure MRI is indicated

  • May help determine risk of seizure recurrence

  • May help determine where in the brain the seizure originated

Long term monitoring ltm

Long Term Monitoring (LTM)

  • Done at an Epilepsy Monitoring Unit (EMU)

  • Diagnostic

  • Investigative

  • Therapeutic change

  • Presurgical

  • Team Approach

Psychogenic nonepileptic seizures

Psychogenic Nonepileptic Seizures

  • 10-45% of refractory epilepsy (referral centers); minority have both NES and ES

  • Females>males

  • Psychiatric mechanism — dissociation, conversion

  • Common association with physical, emotional, or sexual abuse

  • Often requires video-EEG monitoring

     Once recognized, approximately 50% respond well to specific psychiatric treatment

     Epileptic and nonepileptic seizures may co-exist



Seizure triggers

Seizure Triggers?

  • In some people, seizures are triggered by specific events

    • Missing a dose of medication

    • Increased stress level

    • Excessive use of alcohol

    • Drugs such as cocaine

    • A small number of people may be sensitiveto flickering lights (atypical after TBI)

    • Poor sleep

    • Menstrual cycle

    • Many people with epilepsy cannot pinpoint specific triggers for their seizures

  • Avoid triggers if possible

Seizure prevention and improved quality of life

Seizure Prevention and Improved Quality of Life

  • Get a good night’s sleep

  • Eat a healthy diet

  • Exercise regularly

  • Learn how to decrease effects of stress

  • Healthy support network (including employer)

  • Develop routine to take medications on schedule and as prescribed

  • Find the right physician

Treatment options in epilepsy

Treatment Options in Epilepsy

  • Antiepileptic drugs (AEDs)

  • Devices

    • Vagus nerve stimulation (VNS®)

    • Feedback devices in development

  • Epilepsy surgery

  • Alternative therapies

How many anti epileptic drugs aeds are there

How Many Anti-Epileptic Drugs(AEDs) Are There?

Drugs@FDA: FDA Approved Drug Products. Available at:

Anti epileptic drug aed considerations


  • Spectrum of action (broad vs. narrow)

  • Parenteral administration/loading options

  • Pharmacokinetics and drug interactions

  • Concomitant disease

  • Birth control

  • Likely adverse effects

  • Efficacy

  • Cost

Possible side effects

Possible Side Effects

  • Fatigue

  • Memory and concentration difficulties

  • Mood change (depression, anxiety)

  • Change in sleep

  • Dizziness

  • Nausea

  • Vision change (blurred, double)

  • Unsteady walking

  • (Weight change)

Other treatments

Other Treatments

  • 30% to 40% of people with epilepsy continue to have seizures despite treatment

  • Ketogenic diet

    • High-fat, low-carb diet

    • Mostly used in very young children with difficult-to-control generalized epilepsies

  • Vagal Nerve Stimulator (VNS)

  • Surgery

Surgical treatment

Surgical Treatment

 Potentially curative

  • Resection of epileptogenic region (“focus”) avoiding significant new neurologic deficit

     Palliative

  • Partial resection of epileptogenic region

  • Disconnection procedure to prevent seizure spread

    • Callosotomy

    • Multiple subpial transections

Seizures epilepsy associated with tbi

Surgery for TLE Wiebe, Blume, Girvin, Eliasziw. A Randomized Controlled Trials of Surgery for Temporal Lobe Epilepsy; NEJM, 2001

Seizure first aid

Seizure First Aid

  • Call for help

  • Look at the time

  • Observe

  • Create safe environment

  • Do not place anything in the mouth

  • If easily possible, turn person on their side

  • Most seizures last less than 2 minutes

Co morbidities




  • Greater risk of developing epilepsy

  • More common in people with epilepsy

  • Greater risk of suicide

  • Undertreated in many people with epilepsy

The different faces of depression in epilepsy

The “Different Faces” of Depression in Epilepsy

  • Interictal

    • Range from hours to days

    • Anhedonia, poor frustration tolerance

  • Ictal

    • Anhedonia

    • Guilt

    • Suicidal ideation

  • Post-ictal

  • Kanner 2003

    Other co morbidities

    Other Co-Morbidities

    • Anxiety

    • Bipolar disease

    • Psychosis

    • Memory dysfunction

    Quality of life

    Quality of Life

    Special situations

    Special Situations

    Status epilepticus se

    Status Epilepticus (SE)

    • 30+ minutes of seizure activity

    • Can be life threatening

    • Can be first presentation of epilepsy

    • Treated as an emergency

    Women with epilepsy

    Women With Epilepsy

    • Birth control and drug interactions

    • Preconception counseling

    • Folic acid

    • Bone health (important for men too)

    Safety issues

    Safety Issues

    • Water safety (e.g., swimming, boating, skiing)

    • Employment/safety-sensitive jobs (e.g., commercial truck driver, pilot, medical personnel, military service)*

    • Trauma/emergency care

      • Seizure-related injuries

    • Driving

    • SUDEP (sudden unexplained death in epilepsy)


    Dispelling myths

    Dispelling Myths

    • Biggest problem faced by individuals with epilepsy is DISCRIMINATION

    Epilepsy foundation

    Epilepsy Foundation

    Modern case

    Modern Case

    Seizures epilepsy associated with tbi

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