Tag: head trauma

Post Traumatic Epilepsy: when head trauma leaves behind a seizure disorder

braindiseases9 Comments

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.

Persistent vegetative state or Minimally conscious state: a question and an answer

braindiseasesLeave a comment
Dear Dr. SethiI am really confused and I would be very grateful if you could help me. My 40 years old brother had a car accident six months ago and suffered a diffuse axonal injury. He was a university teacher, very intelligent. He is slowly improving and his evolution is very similar to what you described in your first post. Now he looks to where we ask him to look but he does not respond to other verbal commands. The doctors sent him home 2 weeks ago and did not say if he is PVS or MCS. We do not have good care centers in the city and the neurologists said there is nothing we can do to help him. We should just feed him and avoid infections. He is getting good physical therapy, now. We talk to him a lot, he watches TV and listens to music. We even give him small quantities of sauces and juices to stimulate his taste. We believe that our love will help him more than being away from his family in a rehab center. But we are afraid of doing less than we should. Are the neurologists right? Is it possible to provide enough stimulation at home? Is there any literature to guide us on this path? Thank you very much for your attention. By the way, we live in Brazil and I apologize for the bad english.

c
braindiseases Dear C,
thank you for writing in to me. I apologize for the delay in my reply. As I stated in my posts, it is at times indeed difficult to prognosticate about patients who have suffered a traumatic brain injury. You say your brother’s neuroimaging studies showed diffuse axonal injury (DAI).
I shall not use words like PVS or MCS. I shall try to explain a few things with examples. So here goes and I speak from your perspective.1. Just what is the level of my brother’s consciousness. Is he fully consciousness or is he not. There are different grades of consciousness–people use words like comatosed, semi-comatosed, drowsy, somolent, sleepy)
2. He may be conscious but not aware ( consciousness is intact but there is no awareness. By awareness I mean to one’s own need like hunger, a full bladder and so forth. Is he aware he is hungry? Is he aware he has a full bladder and needs to void? Awareness about surroundings. Who is that person standing next to me? Is that my sister?)
3. He is conscious with limited awareness. There are days or moments in a day when he seems more aware. He smiled at you when you came to see him today. He said or attempted to say something. He squeezed your hand.

So as you can see these disorders of consciousness are very fluid conditions. The brain is not static. There are patients who may be in one stage and may progress or deteriorate into another state. As neurologists we are now acutely aware of how limited our understanding is of these disorders of consciousness.

So this is what I advise:
1. Firstly you are dealing with an extremely tough condition. One that unfortunately has no good treatment or possibly outcome. So hang in there and have faith.
2. He should be assessed by his neurologist at some future date. Remember what I said above. Patients evolve and their neurological examination changes.
3. Stimulation cannot hurt him and so interacting with your brother is good.
4. Infections like pneumonia (patients usually have a weak cough reflex and may aspirate their food leading to a lung infection), bed sores and urinary tract infection are the main things you need to watch out for. These frequently lead to poor outcomes and hence should be aggressively identified and treated.
5. Good physical therapy forms the cornerstone of any treatment regime. I would encourage that. Maybe he can go for physical therapy once or twice a week. Rest of the days, it can be done at home.
6. There is hope on the way. New research is been done. There are recent reports of improved outcome/ dramatic improvement in patients in MCS who underwent neurostimulation.

I hope I have been of help to you.

Personal Regards,
Nitin Sethi, MD

Epidural hematoma: when a “minor” head injury may prove to be fatal

braindiseases4 Comments

Epidural hematoma: when a “minor” head injury may prove to be fatal

 

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

Many of you must have read about the tragic demise of actress Natasha Richardson from blunt (closed) head trauma she sustained after falling on a ski slope. While exact details about the extent and nature of her injuries are unclear, it drew attention to blunt (closed) head trauma. I shall discuss about the same here.

Broadly speaking head injuries can be of two types: penetrating head injuries and closed head injuries. An example of a penetrating head injury is a gun shot wound to the head or when a person is involved in a motor vehicle accident with significant polytrauma (including fracture of the skull and bleeding into the brain). Penetrating head injuries are usually easily identified by first responders (emergency medical services such as the ambulance crew responding first to the call). Usually there is an obvious scalp laceration and blood is seen oozing from the site of the injury. Later when the patient is transferred to the hospital, the extent of the injury can be better documented. For this usually a CT scan of the brain is done (at times a MRI brain may be carried out). Penetrating head injuries vary depending upon the mechanism of injury (example velocity, trajectory and size of the bullet in the case of gun shot wounds to the head). Patients with penetrating head trauma are critical and require urgent stabilization usually in an intensive care setting.

It is the closed head injuries though which can be a little deceiving and that is where I shall like to steer this discussion. The mechanism of closed head injuries is usually blunt trauma to the head (example a fall, a blow to the head while boxing and so on). One special type of closed head injury is a concussive injury from an improvised explosive device (IED). These IED related injuries have become the signature injury in the battlefields of Iraq and Afghanistan. But moving away from the battlefield, closed head injuries are frequent. Most of them are mild as the ones sustained while playing contact sports like football or boxing or when you get up in the middle of the night to go get a glass of water only to bump your head against a door. One “sees stars” for a while but is none the worse for wear apart from a bruised head and maybe ego (especially if you are like me and love to box). But can seemingly innocuous looking closed head injuries prove to be fatal? Can a “minor” fall or blow to the head kill you?

Well yes and this brings us to epidural hematomas. Let us assume you suffer a “minor” closed head injury. What you may ask exactly is “minor” closed head injury. Well it usually refers to an injury in which there is no prolonged loss of consciousness (example is a concussion after a blow to the head or a fall). As the scalp is not lacerated there is no obvious external bleeding. The patient may suffer a minor black out (loss of consciousness for a few seconds to minutes) but soon is awake and seems alert and able to answer questions.

 Imagine a boxer, who walks into a straight right. BOOM!!! Down he goes. The referee counts him out. It is a KO. The ring side doctor rushes in. The boxer eyes are glazed but he is coming around and slowly is able to get up and walk out of the ring unassisted. Nothing but a bruised ego and a black eye. He shall live to fight another day you may say as a spectator but the next day you read in the papers that the boxer was found dead in his bed. What happened here? Well the answer is simple. Even though the boxer seemed to have a suffered a “minor” closed head injury, a far more sinister injury process started silently in the brain. The blow to the head caused one of the small arteries (usually a branch of the middle meningeal artery) to start leaking blood. This blood starts collecting in the potential space between the brain and the skull (we call this the epidural space and hence a collection of blood in this space is called an epidural hematoma). As the leak is small, the patient seemingly recovers and looks fine. He may answer questions appropriately and hence may decide not to seek further medical attention. This interval where the patient (in our case our boxer) looks fine and seems to have recovered from the head blow is called the LUCID INTERVAL (the patient is lucid, makes sense and looks normal). But things are already starting to go wrong. The small leak from the ruptured blood vessel leads to progressive accumulation of blood in the epidural space. When the epidural hematoma becomes large, it has no place to expand (remember there is a rigid bony skull which prevents the blood from coming out). So the underlying brain starts getting squashed. This leads to a depression in the level of consciousness as the pressure inside the brain increases. If the elevated intracranial pressure is not brought down urgently the patient may die (we call this herniation of brain due to elevated intracranial pressure).

Could our boxer have been saved? Yes by all means. If he had been kept under observation (sometimes we like to observe patients with closed head trauma overnight in the hospital), then the first signs of raised intracranial pressure would have been picked up. Usually this is a change in the level of consciousness (the boxer would have become drowsy or hard to wake up, may have complained of headache). An urgent CT scan would have revealed the epidural collection of blood and neurosurgical evacuation of the blood would have been carried out (the skull is opened and the blood is drained out. The bleeding vessel is identified and cauterized to achieve homeostasis).

So what are the take home points from our boxer’s story?

-some “minor” looking closed head injuries can indeed prove to be fatal.

-patients should be observed after a closed head injury. If the decision is made not to go to the hospital, have a friend or family member check on the patient at multiple points.

-the earliest change in the patient’s level of consciousness warrants a stat transfer to the nearest hospital and further investigations.

Post Concussive Syndrome

braindiseasesLeave a comment

In this post I thought I would talk a little about what is called post concussive syndrome (PCS). Before we discuss PCS, we need to understand just exactly what is a concussion. Unfortunately though there has been realms of data generated on this, the word concussion still remains quite ill-defined in the medical literature. Basically it refers to a brief loss of consciousness. Lets use an example. You are in the ring against Iron Mike. You have your right and left going but walk into one of Iron Mike’s jabs. Boom your legs give away under you and you are on the mat unconscious seeing “stars”. You are “out” for a few seconds and then boom you come out and are looking up at the referee to ask “where am I? what happened to me?”

Concussion may then also be referred to as a minor head trauma or rather a minor closed head trauma accompanied by brief loss of consciousness. Closed since there is no breach in the skull. The head injury occurs but nothing penetrates the skull. Concussions are thus common and they may occur during a MVA, sports related concussions are common (injuries during football, ice-hockey, boxing and other contact sports where blows to the head may occur). The exact mechanism why there is that bried period of unconsciousness which then resolves and the person wakes up is not fully elucidated. The thinking is that during the concussion, the brain is subjected to mechanical and kinetic forces which “shake” the brain inside the rigid cranium. The brain though is free to move inside the skull, it is attached by the brainstem which is relatively immobile. So as the brain turns on its axis, there is transient dysfunction of the brainstem and this leads to loss of consciousness and the person blacks out.

Concussions are usually not life threatening and the patient comes around in a few seconds to a few minutes. Those associated with a prolonged period of unconsciousness though need to be evaluated in the hospital to make sure there is nothing serious or structural such as an intracranial hemorrhage (bleed) into the brain or outside the brain but inside the skull (epidural hematoma).  There are guidelines with respect to sports related concussion injuries and usually the doctor at the side of the play field makes a decision whether it is safe for the player to play again during that game or should he sit out the rest of the game. Multiple concussive injuries increase the risk of sudden death (no one quite knows by what exact mechanism) and hence concussive injuries in professional players like those who play football do deserve special attention.

Let us now turn to what is called PCS. Again there has a lot which has been written about PCS but this syndrome is ill-defined and its etiology is far from clear. Patients who have suffered a concussion frequently complain of memory problems following the concussion. Apart from memory difficulties these patients may complain of mood changes been too irritable or short tempered, balance problems and unsteady gait, dizziness, headaches, fatigue and lack of energy. This constellation of signs and symptoms with a preceeding history of concussion is what has been referred to as PCS. When these patients present to neurologists, we investigate them but most of the time all the tests come back as “normal”. Their imaging studies like CT scan head and MRI brain are normal.

PCS is usually treated symptomatically. If headache is the major complain we treat the headache. If dizziness is the major complaint we treat with an antivertigo drug. At times low dose antidepressants may be helpful. The natural history of this condition is good and most patients recover in due course and are able to go back to their day to day life.

Nitin Sethi, MD