Despite a large body of experimental evidence suggesting that posttraumatic epilepsy can be prevented, there is no generally accepted pharmacological regimen for posttraumatic seizure prophylaxis. This article describes a phenytoin anticonvulsant regimen specifically tailored for the patient with acute head injury and designed to provide immediate and sustained plasma concentrations of phenytoin between 10 and 20 microgram/ml. Initially, an intravenous phenytoin dose of 11 mg/kg body weight is immediately followed by an intramuscular dose of 13 mg/kg body weight. This is followed by daily intramuscular maintenance doses, usually 8.8 mg/kg body weight, until oral medication can be tolerated. Maintenance dosage adjustments, when necessary, are based on serial plasma concentrations of the drug. Eighty-four patients with severe head injuries with substantial risk of posttraumatic epilepsy were administered this regimen. Only 6% of these patients had seizures during the first year after injury (first week excluded), and this is considerably less than the rates reported elsewhere in the literature. Only one-third of these patients are known to have continued to take phenytoin after the first month, and only half of these had plasma phenytoin concentrations above the desired minimal level. The greatly reduced incidence of posttraumatic seizures in these patients, despite the low rate of long-term drug compliance, suggests that a prophylactic effect, rather than a suppressive effect, is produced.
Out of a total 157 hospitalized head-injured children, twelve years of age and under, fifteen were considered to be severe, three of whom died within 72 hours of admission. Nine children with closed head injuries who were in coma for at least 24 hours (did not open eyes, speak, or follow commands), with absent or impaired oculocephalic reflex, impaired pupil reactivity to light, and who were decerebrating for at least twelve hours, were studied. Five were given high dose dexamethasone therapy (1 mg/kg) within six hours of injury, repeated at six hours, and then maintained at 1 mg/kg/day for eight days, and four either received none or were treated with a low dose regimen (0.25 mg/kg/day). In those receiving high dose therapy, intracranial pressure waves were noticeably less, peak intracranial pressure was lower, and intensive care and hospital stay were shorter. It was also noted that in the high dose therapy group spontaneous eye opening and speech returned sooner, and all were considered to have returned to their premorbid status by six months following injury. Of the no steroid or low dose group, one died, and of the remainder at six months one was aphasic and still decerebrating, another was aphasic and severely handicapped, and the third returned to school seven months after injury.
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