New Practice Parameters for Treatment of Seizures
Abstracts & Commentary
Sources: Chang BS, Lowenstein DH. Antiepileptic drug prophylaxis in severe traumatic brain injury. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2003;60:10-16; Hirtz D, et al. Treatment of the child with a first unprovoked seizure. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2003;60:166-175.
Practice parameters from the AAN "are strategies for patient management that assist physicians in clinical decision-making." These recommendations are derived from a thorough review that not only summarizes the available evidence-based medicine but, more importantly, assesses the quality of the data being reviewed.
Severe head traumatic brain injury (TBI) involves loss of consciousness or amnesia for 12-24 hours, intracranial hematoma, depressed skull fracture and/or brain contusion. About 10-12% of patients with severe TBI will develop seizures. Arbitrarily, these posttraumatic seizures are defined as "early" if they occur within 7 days of the injury or "late" if they occur thereafter. Chang and Lowenstein conclude that "prophylaxis with phenytoin in patients with severe TBI is established as effective in decreasing the risk of early posttraumatic seizures." By contrast, "prophylaxis with phenytoin, carbamazepine, or valproate . . . is probably not effective in decreasing the risk of late posttraumatic seizures."
Hirtz and associates raise the question of whether it is appropriate to treat children and adolescents who have experienced a first seizure with antiepepileptic drugs (AED). They recommend that "treatment with AED is not indicated for the prevention of the development of epilepsy," but "treatment with AED may be considered in circumstances where the benefits of reducing the risk of a second seizure outweigh the risks of pharmacologic and psychosocial side effects." Neither recommendation meets the standard of being supported by a convincing Class I study.
Commentary
While it is useful to have common clinical practice codified in such a systematic way, these 2 practice parameters leave us with the disheartening conclusion that there is nothing new under the sun regarding seizure prophylaxis. We know that AEDs are effective at suppressing seizures. We also know that their effectiveness comes with the risk of untoward side effects. But, what are the mechanisms underlying epileptogenesis, and can we develop therapies to interfere with this process? This is really the issue common to treating TBI and unprovoked childhood seizures.
Recommendations for future research should be even more prescriptive than the present practice recommendations. It would be of great interest to conduct prospective, randomized, controlled trials of the newer AEDs. Trials could include topiramate and zonisamide (which are reported to have neuroprotective properties) or levetiracetam (which is supposed to suppress kindling models of epileptogenesis). The goal of the study would be to prevent the development of late posttraumatic seizures or epilepsy in children following a first unprovoked seizure. Such studies offer the promise of important future revisions of the current practice parameters. — Andy Dean
Dr. Dean is Assistant Professor of Neurology and Neuroscience, Director of the Epilepsy Monitoring Unit, Department of Neurology, New York Presbyterian Hospital—Cornell Campus.
Practice parameters from the aan are strategies for patient management that assist physicians in clinical decision-making. These recommendations are derived from a thorough review that not only summarizes the available evidence-based medicine but, more importantly, assesses the quality of the data being reviewed.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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