Immediate Posttraumatic Seizures: Is Routine Hospitalization Necessary?

Abstract

Objective: A recent Internet survey of pediatric neurosurgeons showed that 86% routinely admitted children with immediate posttraumatic seizures (PTS) for a brief period of observation. We wished to determine whether certain children meeting predefined criteria could instead be safely discharged from the emergency room. Methods: We reviewed the records of children admitted during the past 5 years with a diagnosis of seizure and head injury. Children with a minor head injury, a PTS occurring within 24 h of injury and no intracranial abnormalities on admission CT scan were included. Children with previous neurological conditions, a history of prior seizures (other than PTS or febrile seizures), a prior history of anticonvulsant use, or intracranial abnormalities on the admission CT scan were excluded. Records were abstracted for child’s age, gender, length of admission, previous history of PTS or febrile seizures, mechanism of injury, location of impact, time between impact and PTS, the number, length and type of PTS, Glasgow Coma Score (GCS) on admission, subsequent complications and hospital costs. Results: Seventy-one children met the inclusion criteria. Eleven children presented to the emergency room with prolonged seizures, transient apnea or persistently low GCS and required admission to the intensive care unit (ICU). Among the 60 remaining children with simple PTS, none had further seizures during the follow-up period, and none had significant complications. The average cost of hospitalization was known for 58 children; after excluding the costs for 5 patients who were admitted to the ICU, the average hospital cost amounted to USD 1,615 per patient. Conclusions: Our data suggest that children with isolated minor head injuries and simple PTS who recover fully in the emergency room, whose CT scans show no intracranial abnormalities and who have no prior history of neurological disease, epilepsy or anticonvulsant use are at low risk for recurrent seizures or neurological complications, and could potentially be sent home to a reliable caretaker and a stable home situation. However, because of the limited sample size in this study, the statistical risk of a bad outcome may be as high as 9%; we therefore suggest that much larger studies are potentially needed before this becomes a standard policy.

Prevalence of Brain Injuries and Recurrence of Seizures in Children With Posttraumatic Seizures

“…Previous studies about children with PTS are few and limited by small sample sizes and/or retrospective designs, which limit the accuracy and precision of the risk estimates described . One smaller prospective study, however, had similar results to ours both in terms of prevalence of TBIs on CT and that none of the children without CT abnormalities had recurrent seizures after ED discharge .…”

“…The frequency of TBIs on CT in children with PTS has not been precisely quantified, with reported estimates ranging from as low as 2% to as high as 16% . Hospitalization of children with PTS occurs in 48% to 80%, mostly to monitor for seizure recurrence or clinical deterioration or because of the need for neurosurgery . For children with immediate PTS and normal CT scans, however, two studies have suggested that the risk of seizure recurrence may be low enough to safely discharge these patients home from the ED …”

Traumatic Brain Injury Induces Rapid Enhancement of Cortical Excitability in Juvenile Rats

“…Seizure-like events were detected on average 5.57 ± 1.4 times in the second week of recording after CCI and had an average duration of 134.2 ± 11 seconds. In humans, epileptiform activity that occurs immediately after injury (<24 h) is thought to be direct injury induced and a poor predictor of PTE [46,47]. However, even a single “late” seizure that occurs more than 1 week after injury has a 65–90% chance of progressing to recurrent seizures and PTE [48,49].…”

Neurocysticercosis in Radiographically Imaged Seizure Patients in U.S. Emergency Departments1

“…Nearly half of the seizure patients in our study were admitted to the hospital. The average cost of hospitalization for seizures in one study was $1,615 per patient, not including physician charges (26). The economic toll extends beyond such direct costs.…”