Pharmacological management of post-traumatic seizures in adults: current practice patterns in the UK and the Republic of Ireland

Abstract

Background Patient selection for seizure prophylaxis after traumatic brain injury (TBI) and duration of anti-epileptic drug treatment for patients with early post-traumatic seizures (PTS), remain plagued with uncertainty. In early 2017, a collaborative group of neurosurgeons, neurologists, neurointensive care and rehabilitation medicine physicians was formed in the UK with the aim of assessing variability in current practice and gauging the degree of uncertainty to inform the design of future studies. Here we present the results of a survey of clinicians managing patients with TBI in the UK and Ireland. Materials and methods An online survey was developed and piloted. Following approval by the Academic Committee of the Society of British Neurological Surgeons, it was distributed via appropriate electronic mailing lists. Results One hundred and seventeen respondents answered the questionnaire, predominantly neurosurgeons (76%) from 30 (of 32) trauma-receiving hospitals in the UK and Ireland. Fifty-three percent of respondents do not routinely use seizure prophylaxis, but 38% prescribe prophylaxis for one week. Sixty percent feel there is uncertainty regarding the use of seizure prophylaxis, and 71% would participate in further research to address this question. Sixty-two percent of respondents use levetiracetam for treatment of seizures during the acute phase, and 42% continued for a total of 3 months. Overall, 90% were uncertain about the duration of treatment for seizures, and 78% would participate in further research to address this question. Conclusion The survey results demonstrate the variation in practice and uncertainty in both described aspects of management of patients who have suffered a TBI. The majority of respondents would want to participate in future research to help try and address this critical issue, and this shows the importance and relevance of these two clinical questions. Electronic supplementary material The online version of this article (10.1007/s00701-018-3683-9) contains supplementary material, which is available to authorized users.

Impact of anti-epileptic drug choice on discharge in acute traumatic brain injury patients

“…We recognise that our study was conducted on patients with a GCS 14-15, where dizziness could accurately be assessed, whereas the guidelines for AEDs in TBI are for those patients with severe TBI and GCS < 8. It is clear that AEDs are often prescribed for minor TBI based on clinician choice and it is this cohort that contributed [21]. Whether the AED was indicated at all in these patients was beyond the scope of this study.…”

Head injury in the elderly – an overview for the physician

“…A recent survey of neurosurgical centres in the UK suggests that 50% of neurosurgical centres routinely use anticonvulsants for seizure prophylaxis after brain injury. 50 Current evidence indicates that levetiracetam has a better safety profile and equal efficacy to phenytoin. Levetiracetam may also be associated with better functional outcomes.…”

Seizure Prophylaxis Following Moderate to Severe Traumatic Brain Injury: Retrospective Investigation of Clinical Practice and the Impact of Clinical Guidelines

“…Taken together, the proportion of patients receiving the recommended seizure prophylaxis in this study is lower than that found by others. In survey studies, self-reported use of the recommended seven-day seizure prophylaxis ranges from 38 to 50% [14,23]. Even though 26-65% of TBI patients were found to have been started on seizure prophylaxis in studies that employed medical record reviews, the duration of anticonvulsant use was not reported in two of these three studies [24][25][26].…”

“…A large, multicentre European study found significant variability in indications for and duration of seizure prophylaxis and identified that although nearly all centres reported the use of practice guidelines for the management of TBI, fewer than half had policies that included seizure prophylaxis [21,22]. Surveys in the United Kingdom and Ireland have found that seizure prophylaxis is prescribed by fewer than 60% of responding neurosurgeons, among whom only 38-50% prescribe anticonvulsants for the recommended seven days [14,23]. North American retrospective medical record reviews have found seizure prophylaxis rates of 26-65% [24][25][26].…”