Epilepsy After Traumatic

Brain Injury:
Management & Prognosis

Wardah Rahmatul Islamiyah,dr., Sp.N(K)

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Introduction
SEIZURE

Traumatic Brain
Injury

Long term
neurological
disability

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Harus dipastikan

Pasien Riwayat
Epilepsi Epilepsi post trauma
sebelumnya

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 POST TRAUMATIC SEIZURE (PTS)

POST TRAUMATIC EPILEPSY (PTE)

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 Early PTS
• Terjadi seizure dalam 1 minggu setelah
cedera kepala
• Angka kejadian 4-25% jika tidak dicegah

Late PTS
• Terjadi seizure lebih dari 1 minggu setelah
cedera kepala
• Angka kejadian 9 ‒ 42% jika tidak dicegah

Malison N, Antiepileptic for seizure prophylaxis in Traumatic Brain Injury Patients, 2017. The Bangkok Medical Journal Vol 13 (2):87-90

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 Post Traumatic Epilepsy
• Jika seizure berulang >
7 hari pasca cedera
kepala
Malison N, Antiepileptic for seizure prophylaxis in Traumatic Brain Injury Patients, 2017. The Bangkok Medical Journal Vol 13 (2):87-90

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Epidemiology

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Epidemiology
• KLL menyebabkan cedera & kecacatan 20 ‒ 50 jt
penduduk dunia dan kematian 1.2 jt penduduk/tahun

• Insiden PTS 5 ‒ 50% (variasi manajemen, besar sampel

dan desain penelitian)

• Angka kejadian bila tidak diproteksi

• Early PTS 4 ‒ 25%
• Late PTS 9 ‒ 42%
Malison N, Antiepileptic for seizure prophylaxis in Traumatic Brain Injury Patients, 2017. The Bangkok Medical Journal Vol 13 (2):87-90
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 Epidemiology
• TBI meningkatkan risiko epilepsi 7x lipat
• 5% epilepsi adalah PTE
• Prevalensi PTE 1.9 ‒ 53.3%
Hausted et al, 2020. Epilepsy after severe traumatic brain injury: frequency & injury severity. Barin Injury

• Insiden PTE pada

• Mild TBI 3.6%
• Moderate TBI 6.9%
• Severe TBI 17% (subclinical seizure 20-25%)
Lamar et al, 2014. Post Traumatic Epilepsy: Review of Risks Pathophysiology, dan potential biomarkers. J.Neuropsychiatry Clin Neurosci 26:2

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Epidemiology
• Penetrating Injury (50% PTE)
• Cicatrix in cortex
• Kerusakan jaringan
• Non penetrating injury (30% PTE)
• Toxic effect Hb pd fungsi neuron
• Diffuse Axonal Injury
• Upregulasi sitokin proinflamasi

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Risk factor PTS
• Durasi Post Traumatic Amnesia (PTA) >>> (signifikan), >30
menit
• GCS < 10 saat MRS (<9, <8)
• Lokasi lesi (trauma nonfrontal)
• Cerebral contusion
• Terdapat fragmen tulang atau logam
• Fraktur depresi atau linier
• SDH atau EDH
• Penetrating injury
• Usia
• Ada seizure saat kejadian KLL
• Alkoholism kronis
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Risk factor PTE
• TBI berat dg riwayat kejang saat di RS
• ICH akut atau contusion cortical
• PTA > 24 jam
• Usia ≥ 65 tahun
• Riwayat premorbid depresi

Malison N, Antiepileptic for seizure prophylaxis in Traumatic Brain Injury Patients, 2017. The Bangkok Medical Journal Vol 13 (2):87-90

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Diagnostik
• Neuroimaging konvensional (CT & MRI)
• Limited prognostic information for predicting developmental PTE

• Susceptibility Weighted Imaging (SWI)

• Diffusion Tensor Imaging (DTI)
• Predict PTE (can detect microstructural change)

• Continous EEG to detect subclinical seizure

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Tujuan profilaksis PTS
• Menurunkan insiden seizure
• Mencegah komplikasi herniasi, abnormalitas fisiologi
otak, seizure kronis dan kematian

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Brain Trauma Foundation Guideline

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management
• OAE cegah early PTS not late PTS (RR 0.42)

• Guideline management severe TBI 4th ed oleh Brain

Trauma Foundaiton th 2016 & American Society of
Health system pharmacist 2013
• Rekomendasi: pemberian profilaksi PTS hanya 7 hari pertama
pasca TBI terutama bila ada faktor risiko PTS (level IIA)

• First line : Phenytoin

Loading dose 20 mg/kgBB dlm 24 jam pasca cedera à
Maintenance dose 4 ‒ 8 mg/kgBB/hari (RR 0.27)

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OAE lain sbg profilaksis

LEVETIRACETAM VALPROAT CARBAMAZEPINE

2011, Zafar SN dkk LEV vs
PHT no difference prevent
early n late
1999, Temkin NR dkk, 3 x 100 mg/hari
Loading 20 mg/kgBB iv à maintenance selama 1.5 –
2013, Inaba dkk maintenance 15 2 th à menutunkan early
No difference mg/kgBB/hari dosis terbari PTS 61% drpd placebo,
4x sehari à no difference menurunkan late PTS 20%
with phenytoin (SINGLE STUDY)
2018 retrospective cohort
study: no difference with no
profilaksis

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Other treatment

Steroid Progesteron Citicholine

• Justru • Studi • COBRIT phase

meningkatkan SYNAPSE & III : failed to
kematian PROTECT III : preserve
no benefit functional
mortality and cognitive
status
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Prognosis
• Penetrating injury à parietal lobe epilepsy
• Blunt trauma à temporal and frontral lobe epilepsy
• Chronic TBI survivor à

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Prognosis

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