The nature of posttraumatic epilepsy

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✓ The development, recession, and residua of posttraumatic epilepsy follow natural laws that are imperfectly defined. However, studies from World War I, World War II, the Korean conflict, and the Vietnam War demonstrate the following patterns: 1) The onset of seizures is significantly related to local brain destruction and its location, and to diffuse brain damage, reflected by alteration in consciousness. 2) The incidence of seizures has remained the same from one war to another, in spite of marked improvement in patient transport, surgical techniques, medical management, and the prophylactic use of anticonvulsants in Vietnam. 3) After injuries incurred in combat and support activities, the onset of new cases of epilepsy rises sharply, with approximately 5% having a seizure in the first week, 10% in the first 3 months, 16% in the first 6 months, 23% in the first year, 29% in the first 2 years; after that there is a low, but protracted rate of new cases of epilepsy. 4) Those cases that occur in the first week are less influenced by the agent of injury or local brain damage, thereafter there is a sharp divergence with the more extensive injuries providing the greater number of patients with seizures. 5) In the population at risk, 65% to 75% never have a seizure. In those that do, the development varies in degree, adjudged from frequency of seizures. The latter ranges from a single seizure to a number that defies an accurate count. 6) As new patients with seizures accumulate, earlier patients cease having seizures. Within 5 to 10 years, one-half of the patients have ceased having seizures, with or without therapy. Half of the remainder, about 8% of the injured, have intractable seizures. 7) While there is a clear correlation between severity of injury and onset of seizures, there is no correlation between severity of injury and cessation of attacks. However, there is a correlation between the attack frequency and persistence of seizures. 8) From the preceding, two principal determinants are evident: the constitutional tendency toward seizures (probably a multifactorial genetic trait), and the brain damage. In onset of seizures, both play a part, the constitutional factor apparently determining severity of attacks. In cessation or persistence of seizures, the constitutional factor plays the dominant role.

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Address reprint requests to: William F. Caveness, M.D., National Institutes of Health, Bldg. 36, Rm 4A-27, Bethesda, Maryland 20014.

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Figures

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    Curves for cumulative onset and cumulative cessation. This graph represents the cases of epilepsy in the Korean campaign (109 cases) as a single group with a common time of injury. The shaded area indicates the number of active seizure cases at any given time after injury.

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    Monthly rate of new seizure cases (total, 344) as a percentage of head-injured (total, 1030) in the Vietnam series compared with those from the Korean campaign (109 of 356). An overall similarity is apparent with by far the highest rate within the first month. When the missile injuries alone are considered, the rate of new seizure cases beyond 1 month is almost identical.

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    Frequency distribution of seizures, showing the gradation throughout the population at risk, among 356 head-injured patients in the Korean campaign, who were followed for 10 years.

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    Schematic representation of the distribution of genetic traits toward epilepsy in the general population, shown on the left. Those at the far right of the bell-shaped curve are the most susceptible and may exhibit “spontaneous” seizures. Those at the far left are least susceptible to any influence. When the environmental factor of craniocerebral trauma is added, as indicated on the right, a larger number cross the threshold and exhibit attacks.

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