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對 Posttraumatic epilepsy (PTE) 的危險因子及其預後之探討

對 Posttraumatic epilepsy (PTE) 的危險因子及其預後之探討. R2 詹博棋 , 2005/08/08. 臨床問題. 臨床上對於頭部外傷後的病人 , 其發生癲癇的危險因子有哪些？ 對於腦傷後癲癇 (PTE) 病人 , 其癲癇控制的預後又是如何？. 背景說明. 對於頭部外傷後的病人 , 臨床上偶而會遇到在數年後其發生初次 seizure 的情形 ; 因此 , 希望藉由文獻搜尋來探討 PTE 的危險因子 , 發生率 , 及其相關的預後因子. Posttraumatic epilepsy (PTE).

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對 Posttraumatic epilepsy (PTE) 的危險因子及其預後之探討

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  1. 對Posttraumatic epilepsy (PTE)的危險因子及其預後之探討 R2詹博棋, 2005/08/08

  2. 臨床問題 • 臨床上對於頭部外傷後的病人, 其發生癲癇的危險因子有哪些？ • 對於腦傷後癲癇(PTE)病人, 其癲癇控制的預後又是如何？

  3. 背景說明 • 對於頭部外傷後的病人, 臨床上偶而會遇到在數年後其發生初次seizure的情形; 因此, 希望藉由文獻搜尋來探討PTE的危險因子, 發生率, 及其相關的預後因子.

  4. Posttraumatic epilepsy (PTE) • Immediate epilepsy: • within moments of injury • Represent of true epilepsy? or • The result of arrest of cerebral blood flow or a transient brainstem dysfunction? • Early epilepsy: • within first week • Late epilepsy (Posttraumatic epilepsy, PTE) • Several weeks or months (1 to 3 months mostly)

  5. 期待目標 • 希望能搜尋到相關PTE的危險因子及預後因子, 進而幫助我們對於腦傷後癲癇(PTE)診斷的確立.

  6. 搜尋步驟(1) • Cochrane central register of controlled trials: • Combine “traumatic brain injury” with “epilepsy”0/3 • Combine “traumatic brain injury” with “seizure” 0/2 • Posttraumatic epilepsy  1/3 , no abstract • Manaka S Cooperative prospective study on posttraumatic epilepsy: risk factors and the effect of prophylactic anticonvulsant. [Clinical Trial. Journal Article. Multicenter Study. Randomized Controlled Trial] Japanese Journal of Psychiatry & Neurology. 46(2):311-5, 1992 Jun. • Posttraumatic seizure  0/1 • Side effects and mortality associated with use of phenytoin for early posttraumatic seizure prophylaxis.

  7. 搜尋步驟(2) • Cochrane Database of Systemic Reviews: • Combine “traumatic brain injury” with “epilepsy”0/3 • Combine “traumatic brain injury” with “seizure” 0/1 • Posttraumatic epilepsy  0 • Posttraumatic seizure  0/2

  8. 搜尋步驟(3) • Cochrane Library • Combine “traumatic brain injury” with “epilepsy”0/5 • Combine “traumatic brain injury” with “seizure” 0/11 • Posttraumatic epilepsy  0/2 • Posttraumatic seizure  0/5

  9. 搜尋步驟(4) • EBM: ACP Journal club: nil • Combine “traumatic brain injury” with “epilepsy”0 • Combine “traumatic brain injury” with “seizure” 0 • Posttraumatic epilepsy  0 • Posttraumatic seizure  0

  10. 搜尋步驟(5) • PubMed: • Combine “posttraumatic epilepsy” with “prognosis ” 7/29 • Combine “posttraumatic epilepsy” with “risk factor ” 3/5 • Combine “posttraumatic seizure” with “prognosis”  2/7 • Combine “posttraumatic seizure” with “risk factor”  2/3

  11. 結果摘要 (1) • Longitudinal cohort design • Risk of seizure recurrence after the first late posttraumatic seizure.(Arch Phys Med Rehabil. 1997 Aug;78(8):835-40.) • The cumulative incidence of recurrent late seizures was 86% by approximately 2 years. . • The relative risk of recurrence was highest in: • a history of acute SDH • prolonged coma (ie, longer than 7 days).

  12. 結果摘要 (2) • Cohort study • Seizures after head trauma: a population study.(Neurology. 1980 Jul;30(7 Pt 1):683-9.) • The risk of posttraumatic seizures • Severe (brain contusion, ICH, or >24 hours unconsciousness or amnesia): • 7.1% within 1 year • 11.5% in 5 years • Moderate (skull fracture or 30 minutes to 24 hours of unconsciousness or amnesia) • 0.7% within 1 year • 1.6% in 5 years • Mild (briefer unconsciousness or amnesia: not significantly greater than in the general population

  13. 結果摘要 (3) • Cohort study • A population-based study of seizures after traumatic brain injuries.(N Engl J Med. 1998 Jan 1;338(1):20-4.) • In the multivariate analysis, significant risk factors for later seizures were • brain contusion with subdural hematoma, • skull fracture, • loss of consciousness or amnesia for more than one day, • an age of 65 years or older. • CONCLUSIONS: The increased risk of seizures after traumatic brain injury varies greatly according to the severity of the injury and the time since the injury.

  14. 結果摘要 (4) • Review, Tutorial • Epidemiology of posttraumatic epilepsy: a critical review.( Epilepsia. 2003;44 Suppl 10:11-7. ) • Significant risk factors, <1st week after injury include: • acute ICH (esp.SDH), younger age, increased injury severity, and chronic alcoholism. • Significant risk factors, >1 week after TBI include • seizures within the first week, acute ICH (esp.SDH), brain contusion, increased injury severity, and age >65 years at the time of injury.

  15. 結果摘要 (5) • Cohort study • Increased risk of late posttraumatic seizures associated with inheritance of APOE epsilon4 allele.( Arch Neurol. 2003 Jun;60(6):818-22) • BACKGROUND: • Inheritance of the apolipoprotein E (APOE) epsilon4 allele is associated with increased risk of Alzheimer disease, progression to disability in multiple sclerosis, and poor outcome after traumatic brain injury. • The relative risk of late posttraumatic seizures for patients with the epsilon4 allele was 2.41 • CONCLUSIONS: • Inheritance of the APOE epsilon4 allele is associated with increased risk of late posttraumatic seizures. In this cohort, this risk appears to be independent of an effect of epsilon4 on functional outcome. A better understanding of the molecular role of APOE in neurodegenerative diseases may be helpful in developing antiepileptogenic therapies.

  16. 結果摘要 (6) • Predictors and dynamics of posttraumatic epilepsy.(Acta Neurol Scand. 1997 May;95(5):257-62.) • High risk for PTE: combination of the 3 variables • prolonged posttraumatic amnesia • depression fracture • cortical-subcortical lesions • poor seizure control: • Combined seizure pattern • high seizure frequency • AED-noncompliance • alcohol abuse predicted

  17. 總結(I) • 目前證據顯示主要的risk factors of PTE如下: • brain contusion • acute SDH • skull fracture, depressed fracture • loss of consciousness or amnesia for more than one day • an age of 65 years or older • Inheritance of the APOE epsilon4 allele is associated with increased risk of late posttraumatic seizures

  18. 總結(II) • 對於 PTE病患,其poor prognosis factors如下: • First seizure > 1 weeks • Combined seizure pattern, • high seizure frequency, • AED-noncompliance • alcohol abuse

  19. Thanks for your attention!

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