Posttraumatic seizures (PTSs) are the most common complication following a traumatic brain injury (TBI) and may lead to posttraumatic epilepsy. PTS is well described in the adult literature but has not been studied extensively in children. Here, the authors utilized the largest nationwide registry of pediatric hospitalizations to report the national incidence, risk factors, and outcomes associated with PTS in pediatric TBI.
The authors queried the Kids’ Inpatient Database (KID) using ICD-9-CM codes to identify all patients (age < 21 years) who had a primary diagnosis of TBI (850.xx–854.xx) and a secondary diagnosis of PTS (780.33, 780.39). Parameters of interest included patient demographics, preexisting comorbidities, hospital characteristics, nature of injury (open/closed), injury type (concussion, laceration/contusion, subarachnoid hemorrhage, subdural hematoma, or epidural hematoma), loss of consciousness (LOC), surgical management (Clinical Classification Software code 1 or 2), discharge disposition, in-hospital complications, and in-hospital mortality. The authors utilized the IBM SPSS statistical package (version 24) for univariate comparisons, as well as the identification of independent risk factors for PTS in multivariable analysis (alpha set at < 0.05).
The rate of PTS was 6.9% among 124,444 unique patients hospitalized for TBI. The utilization rate of continuous electroencephalography (cEEG) was 0.3% and increased between 2003 (0.1%) and 2012 (0.7%). The most common etiologies of TBI were motor vehicle accident (n = 50,615), accidental fall (n = 30,847), and blunt trauma (n = 13,831). However, the groups with the highest rate of PTS were shaken infant syndrome (41.4%), accidental falls (8.1%), and cycling accidents (7.4%). In multivariable analysis, risk factors for PTS included age 0–5 years (compared with 6–10, 11–15, and 16–20 years), African American race (OR 1.4), ≥ 3 preexisting comorbidities (OR 4.0), shaken infant syndrome (OR 4.4), subdural hematoma (OR 1.6), closed-type injury (OR 2.3), brief LOC (OR 1.4), moderate LOC (OR 1.5), and prolonged LOC with baseline return (OR 1.8). Surgically managed patients were more likely to experience PTS (OR 1.5) unless they were treated within 24 hours of admission (OR 0.8). PTS was associated with an increased likelihood of in-hospital complications (OR 1.7) and adverse (nonroutine) discharge disposition (OR 1.2), but not in-hospital mortality (OR 0.5). The overall utilization rate of cEEG was 1.3% in PTS patients compared with 0.2% in patients without PTS. Continuous EEG monitoring was associated with higher rates of diagnosed PTS (35.4% vs 6.8%; OR 4.9, p < 0.001).
PTS is common in children with TBI and is associated with adverse outcomes. Independent risk factors for PTS include younger age (< 5 years), African American race, increased preexisting comorbidity, prolonged LOC, and injury pattern involving cortical exposure to blood products. However, patients who undergo urgent surgical evacuation are less likely to develop PTS.
ABBREVIATIONSAED = antiepileptic drug; AHRQ = Agency for Healthcare Research and Quality; CCS = Clinical Classification Software; cEEG = continuous electroencephalography; EDH = epidural hematoma; HCUP = Healthcare Cost and Utilization Project; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; KID = Kids’ Inpatient Database; LOC = loss of consciousness; PTS = posttraumatic seizure; SAH = subarachnoid hemorrhage; SDH = subdural hematoma; TBI = traumatic brain injury.
Correspondence Paul M. Arnold: University of Kansas Medical Center, Kansas City, KS. firstname.lastname@example.org.
INCLUDE WHEN CITING Published online September 21, 2018; DOI: 10.3171/2018.6.PEDS1813.
Disclosures Dr. Paul Arnold has commercial relationships with Z-Plasty (stock, stock options, or other ownership interest); Medtronic Sofamor Danek (salary and any payment for services not otherwise identified as salary, such as consulting, fees, honoraria, paid authorship, or other payments for services); Stryker Spine (sponsored or reimbursed travel, salary and any payment for services not otherwise identified as salary, such as consulting, fees, honoraria, paid authorship, or other payments for services); AOSpine North America (sponsored or reimbursed travel); Invivo (salary and any payment for services not otherwise identified as salary, such as consulting, fees, honoraria, paid authorship, or other payments for services); SpineEx (shares in company); and Asterias (financial, data and safety monitoring board); and noncommercial relationships with Lumbar Spine Research Society (nonfinancial, co-chair of Program Committee); AANS/CNS Joint Section Neurotrauma (executive committee); and CSRS (nonfinancial, board of directors).
BakrABelliA: A systemic review of levetiracetam versus phenytoin in the prevention of late post-traumatic seizures and survey of UK neurosurgical prescribing practice of antiepileptic medication in acute traumatic brain injury. Br J Neurosurg[epub ahead of print] 2018
ChangBSLowensteinDH: Practice parameter: antiepileptic drug prophylaxis in severe traumatic brain injury: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology60:10–162003
HCUP: Clinical Classifications Software (CCS) for ICD-9-CM. Rockville, MD: Agency for Healthcare Research and Quality2011. (https://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp) [Accessed July 30 2018]
LiesemerKBrattonSLZebrackCMBrockmeyerDStatlerKD: Early post-traumatic seizures in moderate to severe pediatric traumatic brain injury: rates, risk factors, and clinical features. J Neurotrauma28:755–7622011
RitterACWagnerAKFabioAPughMJWalkerWCSzaflarskiJP: Incidence and risk factors of posttraumatic seizures following traumatic brain injury: a Traumatic Brain Injury Model Systems study. Epilepsia57:1968–19772016
WeintraubAHGerberDJKowalskiRG: Posttraumatic hydrocephalus as a confounding influence on brain injury rehabilitation: incidence, clinical characteristics, and outcomes. Arch Phys Med Rehabil98:312–3192017