Recently I have seen a few patients with post traumatic epilepsy and hence I decided it might be appropriate to talk about the same in more depth.
Before we begin though I want to wish all the readers of my blog from around the world a very Happy and Healthy New Year 2012. May it bring you not just a healthy brain but also a healthy mind.
Ok now to the topic at hand. Just what do neurologists and neurosurgeons mean when they say you have post traumatic epilepsy? As the name suggests post traumatic epilepsy (PTE) refers to epilepsy/seizures starting after a patient sustains head trauma. Let me explain with an example. Let us assume John is involved in an motor vehicle accident. While driving down the FDR drive late one night he falls asleep behind the wheel of his car. The roads are icy! John’s car spins out of control, jumps the curb and hits an embankment. John who is not wearing a seat belt gets thrown out of the car striking his head first on the windscreen and then on the unyielding asphalt concrete. A passerby witnesses the accident and calls 911. EMS are on the screen within minutes but John is not moving. His neck is stabilized in a hard collar and he is rushed to the nearest hospital. Glasgow coma scale (GCS) on arrival is documented to be 5. John is not responding to verbal commands and is rushed to the CT scanner for a stat head CT. CTscan shows all is not well. John has sustained significant head trauma. He has a fracture of the right temporal bone and an underlying epidural hematoma. There are bilateral frontotemporal contusions which are increasing in size. In addition there is diffuse subarachnoid hemorrhage. The epidural hematoma is evacuated that night itself by the neurosurgeon on call. It is decided that at present the frontal lobe contusions be closely observed. John is transferred to the neurological ICU where he is further stabilized. A close watch is kept on the intracranial pressure.
Fast forward 3 weeks.
After a rocky course in the neurological ICU, John makes a remarkable recovery taking the extent of his head injury into consideration. He is discharged from the hospital to a rehab facility skilled in traumatic brain injuries (TBI). In the rehab facility John makes a slow but steady progress. It is 12 noon and John as usual is working with his physical therapist. He suddenly stops what he is doing. Utters a loud guttural sound, falls down to the floor with his eyes rolled up. The therapist notes that he stiffens up for a few seconds and then starts to shake while frothing at the mouth. The whole seizure lasts for about 2 minutes and then subsides on its own. Post seizure John is confused and disoriented but slowly returns to his baseline in about 40 minutes. An appointment is made for John to see Dr. Feelgood a neurologist in the nearby community hospital.
Dr. Feelgood takes a detailed history and then examines John. You have post traumatic epilepsy John, he says and recommends that John consider starting anticonvulsant therapy without further delay.
The scenario I describe above is unfortunately not uncommon in patients who sustain significant head trauma. In fact head trauma is one of the leading causes of epilepsy in men and women below the age of 40 around the world. The human brain is well protected by an extremely rigid skull and so the trauma has to be significant to cause brain damage and resulting PTE.
MINOR BUMPS AND BRUISES TO THE HEAD DO NOT LEAD TO POST TRAUMATIC EPILEPSY. Post traumatic epilepsy is thus very rarely reported after closed head injuries aka concussions such as those sustained on the sport fields(please read my post about concussions either here or on my website http://braindiseases.info). On the other hand PTE is particularly common after penetrating head injuries such as gun shot wounds to the head or when the skull bone is fractured (especially depressed skull fracture where the bone fragment presses on the underlying brain) or when there is significant intracranial bleeding (remember what John’s CT scan showed: blood in the epidural space and hemorrhage into both the frontal and temporal lobes).
Seizures can occur at any time after a significant head injury. The patient may start having seizures immediately after sustaining the head injury. This is called early post traumatic epilepsy and at times this has a more favorable prognosis. After the blood in the brain goes away and the swelling/pressure in the brain subsides, the seizures may also stop spontaneously. Hence these patients may not need to remain on an anticonvulsant medication for a long time. Seizures though have been reported as far out as 5 years after the head injury. This is called late post traumatic epilepsy and these patients usually need to take anticonvulsant medication for a prolonged duration, at times even lifelong.
Depending on the extent of head trauma, seizures may be easy or hard to control in these brain trauma patients. They are usually prescribed anticonvulsant therapy and seizure control is then closely monitored. If seizures persist then a second or third anticonvulsant may be indicated.
Dr. Feelgood started John on a seizure medication by the name of levetiracetam. He advised John to follow up with him after 3 months. On the 3 month follow up visit, John walked into Dr. Feelgood’s office unaided and with a broad smile on his face.
I feel good, Dr Feelgood he said.
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I’m wondering if a bang on the right side of the head (collision with a large dog) which caused a black eye and bruise down the side of the face could cause seizure activity after 3 months. When worked up previously for something else the EEG was normal. Three months later the EEG showed seizure activity with no apparent seizures. The neurologist said that it could not be caused by the dog collision.
I started having partial seizures that eventualy led to a tonic–clonic seizure (formerly known as a grand mal seizure). This all happened within 3 months after a brain biopsy to get a sample of 1 of the 12 tumors(leisons) that were seen on an MRI presentation. Later on I was diagnosed with Multiple Sclerosis, albeit with leisons that were atypical in regards to location of them in my brain(it’s a long story). But the thing I find interesting about your post here is “head trauma leaves behind a seizure disorder”. I know that seizures can be a symptom of Multiple Sclerosis, but…Only in 2-4% of patients diagnosed with Multiple Sclerosis. If you any thoughts about this, I would be interested to hear them. Thanks so much any input you may have!
My 15 year old daughter hit the back of her head in a basketball game had grade 3 concussion 2 days later developed seizures. This started 12/5/2012 she was started on tegretol 400 twice a day. The seizures over the last few months have become more frequent an it is now 3/17/12 and she takes 400 tegretol 500 keppra 100 lamictal in the morning 600 tegretol 500 keppra at night. Her MRI in December looked good could this concussion still be the cause of the seizures? Should we get another MRI? We are currently waiting for video monitoring are there other things we should be getting done. I feel that the drs just keep throwing more meds at her and she is on lots of meds for a small 15 year old.
Dear Lisa,
thank you for writing in to me about your daughter. When we talk about post traumatic epilepsy, usually it has to be severe head trauma that precipitates the seizure disorder. What do I mean by severe head trauma you may ask. Well any head trauma which leads to a prolonged loss of consciousness is usually classified as severe. Penetrating head injuries, injuries accompanied by a skull fracture especially if the fracture is depressed are severe. Minor “bumps” and “bruises” to the head (minor closed head trauma) do not cause seizures and do not make pre-existing seizure disorder worse.
Personal Regards,
Nitin Sethi, MD
Hello Dr Sethi,
I am a fan of this blog and I wondered if you could shed any light on my situation. I have recently been diagnosed with temporal lobe epilepsy. I am a 30 years old female.
For the last 6 years I have been having surreal deja vu and jamais vu symptoms which I had previously rationalised as ‘flash backs’ following a unusual response to a cocktail of magic mushrooms, red bull and alcohol. This event took place 7 years ago the day before my period. The incident involved a temporary loss of speech and a strange miss recollection of events which impacted on friendships. The event represented something that I found personally traumatic that made me feel depressed and anxious for a number of years.
Last year I started to monitor the deja vu symptoms and noticed they came in clusters and typically pre-menstruation. After noticing the frequency, I discussed my symptoms with my doctor and was referred for an MRI. The MRI showed nothing significant and it was felt that my symptoms may be ‘stress related’. I took this at face value. At the time I had come out of a long term relationship and had a number of demands at work. As such I was referred for counselling (I am still awaiting this).
This year I have been separated from my partner, started a new job and have felt significantly less stressed. As I previously related my symptoms to my period it was suggested that I start taking the pill (Levest). From September to April I only experienced clusters of deja vu twice (once when my ex partner told me of his new relationship and once the day I cancelled my neurologist review).
In April, however, I experienced what appear to be two grand mal seizures in my sleep. I awoke emotional and in pain, and have vague memories of falling out of bed. Stupidly I went to work, had 2 deja vu episodes, came home discovered bruises down my side and suspected a seizure. That night I went to bed, positioned myself on my back and awoke with similar situation and a bite to the tip of my tongue and experienced some difficulty standing. This muscular ache lasted 6 weeks.
Following this, the neurologist made the judegment that I have temporal lobe epilepsy and suggested trying Lamictal and folic acid. However, I decided with my doctor that I would wait and see if the seizures represented an on-going problem.
In May and last month I experienced the clusters of deja vu, but no seizures. These occurred the weekend I had an MRI and the day I was with someone with epilepsy.
I stopped taking the pill last month. My second MRI was clear. An ECG was also clear.
Last week I have had at least 2 more grand mal seizures in my sleep (again pre menstruation), again with a badly bitten tongue and disorientation, for 2 nights consecutively. I went to A and E following the first one. This time I had a left side weakness, but less muscle pain. Instead, however, I have had 6 days’ worth of disorientation and memory loss, to the extent where I was confused about what I was doing at work, who was in the house and where very familiar places were. I think this is consistent with a Posticula state, however 6 days seems long given internet accounts. Friends and family were very concerned. I feel better now, although I think memory is still affected and feel a slight numbness in the right of my head. I started taking Lamictal and folic acid last week.
As far as I know I have had no febrile seizures as a child. I have only ‘blacked out’ once for a few seconds after falling off a climbing frame at secondary school and once when very upset. I have not taken hallucinogenic since my first experience and do not drink in excess. I have hurt my head in the last 3 years to the right of my head (just over a year ago). However, this resulted in a bruise and no concussion. I am not aware of epilepsy in the family (although we have lost contact with my mum’s side). I am aware there is some dementia in the family, their has been an early cardiac arrest resulting in death and there has also been a suicide. My auntie get migranes occassionally and relates this to certain foods.
It is possible I have had pre-existing temporal lobe issues e.g. a dyslexic profile/mild difficulty with literacy since a young age. However, I am academic and have done well professionally.
Around the time of the grand mal seizures I did not feel stressed at all, although the first time had a cold so this may have been latent stress. I ate chinese the night before and wondered about an allergy.
I intend to revisit the neurologist as I am concerned about the rate at which my this issue has advanced in recent months, and that the after effects of the seizure may represent something more permanent or that my seizures are fairly serious given that they occur in clusters and go unobserved during sleep.
I am starting to think the mushroom event was either a symptom or a causative factor in my temporal lobe difficulties (given my memory and language problems during this trip, the fact that the deja vu symptoms seemed to come after this event, and preexsiting literacy difficulties). Alternatively, is it possible that (relatively speaking) mild head injuries has contributed to this or exacerbated this? Do you think my hypothesis about menstruation is valid? There seems to be some commentary on this on line. Could the pill have contributed to the recent advancement of my seizures? Also do you think I should request further scans/test in case this represents a cyst/lesion an allergy? Do you know of technology exist to support may safety at night e.g. gum guards, alarms to notify others? What is the probability this is dissociation and psychological in origin?
I really appreciate you will not have all the answers and my email is complicated! If you have some guidance that will support me in my next consultation with the neurologist I would be very grateful as I feel a bit confused about the whole thing!
Best wishes,
B
Dear Bethany,
thank you for writing in to me and I am glad that you like my blog. Now to your questions. There are certainly points in your history which raise suspicion for ongoing complex partial seizures of temporal lobe origin. That said your events have never been characterized on the EEG. So what we usually do in cases like yours is admission for a video-EEG. This is usually an admission to the epilepsy monitoring unit for 5-7 days. The goal is to capture your typical events on the camera (video) and simultaneously on the EEG. This helps us to determine–are your events truly ictal or are they psychological in nature (non-epileptic events). If they are ictal–where are they originating from–temporal or frontal lobe, left or right. That is the way I would suggest. You should follow up with your doctor and address this in a timely fashion. Of course maintain seizure and fall precautions and do not drive.
I wish you my very best.
Nitin K Sethi, MD
Hi Dr Sethi,
Thank you for replying. I really appreciate that.
I am having some trouble getting an EEG as the neurologists believes that it will be unlikely to show anything if I am not showing activity. I guess if it was timed when I seem more likely to experience seizures this would be worthwhile (?). Would you place much value on the idea the timing of this might be affected by my cycle?
Also, just from your reading and experience would you be more inclined to rule out the notion this could be linked to the drug incident or head injury in this situation?
I should emphasise that although I have talked about depression being an issue in the past this would be not be classified as ‘clinical’ depression. However, I will aknowledge anxiety has been more of an issue. Despite this I have been functional in all aspects of my life (bar my last relationship) and this year anxiety has been less evident.
To my mind, the big seizures feel more of phyiscal than psychological issue.
I must say disassociation greatly concerns me as I know it is linked with conditions like multiple personality, borderline personality and sexual abuse in childhood. I don’t believe people close to me would consider me to me the victum of any of these things.
Drawing on your experience any gut thoughts would be gratefully recieved.
Best wishes,
i am wondering if a driver side impact can cause TLE? I had these weird blackouts and i would remember nothing that happened during them. They would happen on an on and off about a week or to after the accident. I do not remember the initial impact cause I closed my eyes before he hit me and my head was turned to the left looking at him and his friend before impact. For all this time I had severe confusion, forgetfullness to the point I almost set the house on fire cause I left the pan burning on the stove ( could’nt smell the smoke and when I did I did not recognize it), panic attacks after the backouts and not recognizing where I was at, what I was doing, where I was going and why I was there. The memory problems got worse and worse to the point I could not do my job as well as I did before that accident.
By the way I had a photographic memory before the accidnet, not I cannot remember where I put my keys 2 minutes ago. This is frustrating!
Fast forward to 2 1/2 years later. Finally had EEG done and it came back as TLE. I do not remember hitting my head on the head rest but I did find out I have 4 herniated discs from the C2 and C3-C6. The case is done and I settleed but I still cannot get any answers from doctors.
I want to know how can a side impact accident cause TLE?? The other car had about 2000 more lbs. on my car, he saounded like he was at 3500 RPMS ( I used to race cars so I know the sound) injuries but this one is the one I want to know about the most? How is it possible for this to happen to me and not know of it all this time? Why wouldn’t the doctors check out my memory problems that I complained about to them alot?? Can you help me?? I just want an answer to this from which I suffer from?
I suffered a concussion without the loss of consciousness july of 2010,in oct. of 2012 I experienced a seizure and have had them since. I was admitted to the hospital for two days where they did a CT,MRI,and EEG along with numerous blood draws including an artery blood draw. Everything came back normal. I was discharged with adult seizures and told to seek mental help. I was first told that they were stressed induced brought on by emotions. I was put on Keppra where I then began having really bad uncontrollable movement and at one point I could not even walk,at that point I was told that it was a conversion disorder. When I told the shrink he said no,he thought something neurological was wrong. I was hit on the head 15-20 times with the elbow piece of a kitchen sink pipe and also strangled. My question is even though 2 years later could it be possible to have PTS? I am not sure what type as far as grade level my concussion was because when I went to the ER I was not given a MRI or CT scan just looked at my eyes and ears and that was it. I also have heard that MRI’s and CT scan’s as well as EEG’s can have false reads over 5 percent of time,is this true? Any information would be greatly appreciated as I am at a loss as to what to do with this and if it will ever go away!