Management of Epileptic Seizures in Disorders of Consciousness: An International Survey.

Marie-Michèle Briand,Rita Formisano,Nathan Zasler,Anna Estraneo,Wendy L Magee,Aurore Thibaut,Olivier Bodart,Nicolas Lejeune

doi:10.3389/fneur.2021.799579

Abstract

Epileptic seizures/post-traumatic epilepsy (ES/PTE) are frequent in persons with brain injuries, particularly for patients with more severe injuries including ones that result in disorders of consciousness (DoC). Surprisingly, there are currently no best practice guidelines for assessment or management of ES in persons with DoC. This study aimed to identify clinician attitudes toward epilepsy prophylaxis, diagnosis and treatment in patients with DoC as well as current practice in regards to the use of amantadine in these individuals. A cross-sectional online survey was sent to members of the International Brain Injury Association (IBIA). Fifty physician responses were included in the final analysis. Withdrawal of antiepileptic drug/anti-seizure medications (AED/ASM) therapy was guided by the absence of evidence of clinical seizure whether or not the AED/ASM was given prophylactically or for actual seizure/epilepsy treatment. Standard EEG was the most frequent diagnostic method utilized. The majority of respondents ordered an EEG if there were concerns regarding lack of neurological progress. AED/ASM prescription was reported to be triggered by the first clinically evident seizure with levetiracetam being the AED/ASM of choice. Amantadine was frequently prescribed although less so in patients with epilepsy and/or EEG based epileptic abnormalities. A minority of respondents reported an association between amantadine and seizure. Longitudinal studies on epilepsy management, epilepsy impact on neurologic prognosis, as well as potential drug effects on seizure risk in persons with DoC appear warranted with the goal of pushing guideline development forward and improving clinical assessment and management of seizures in this unique, albeit challenging, population.

Highlights

Seizure is a transient clinical event that is characterized by abnormal excessive or synchronous neuronal activity in the brain [1]
For acquired brain injury (ABI), it has been established that there are two types of seizures; acute symptomatic seizures [3] [previously called early post-traumatic seizures [4]] that occur within the first week after the ABI, and unprovoked remote symptomatic seizures [5] that happen after the first week post-injury
At least two unprovoked remote symptomatic seizures that occur more than 24 h apart or after a single event that occurs in a person who is considered to have a high risk of recurrence (>60% risk in a 10-year period) define post-traumatic epilepsy (PTE) after ABI [6]

Summary

Introduction

Seizure is a transient clinical event that is characterized by abnormal excessive or synchronous neuronal activity in the brain [1]. At least two unprovoked remote symptomatic seizures that occur more than 24 h apart or after a single event that occurs in a person who is considered to have a high risk of recurrence (>60% risk in a 10-year period) define post-traumatic epilepsy (PTE) after ABI [6]. According to several medical association guidelines such as the American Association of Neurology, the American Academy of Physical Medicine and Rehabilitation, and the Canadian Evidence-based Review of moderate and severe Acquired Brain Injury, acute symptomatic seizures should be prophylaxed with a 1-week course of antiepileptic drug/anti-seizure medication (AED/ASM) treatment such as phenytoin or carbamazepine [7, 8]. Several factors influence the risk of developing unprovoked remote symptomatic seizures, such as the occurrence of acute symptomatic seizures or the severity of the brain injury, among other factors [9]

Objectives

Methods

Results

Discussion

Conclusion