Talk:Post-traumatic epilepsy

The literature frequently uses "post-traumatic seizures" when referring to the chronic condition, maybe because it's broader (they definitely have seizures, but it's harder to diagnose epilepsy). I've been using PTE when a source says "seizure disorder" but when it just uses PTS, I've been putting it in the PTS article. delldot talk 22:18, 1 March 2008 (UTC)

Comments from Colin

I'm copying these from my talk page so they're accessible to everyone. delldot talk 00:15, 4 March 2008 (UTC)

A bit of research

Some sources on Google Books

•  Done Yudofsky, Stuart C.; Silver, Jonathan M.; McAllister, Thomas G. (2005). Textbook Of Traumatic Brain Injury. Washington, DC: American Psychiatric Association. pp. 309–321. ISBN 1-58562-105-6.{{cite book}}: CS1 maint: multiple names: authors list (link)

Chapter 16 has a section on seizures.

•  Done Swash, Michael (1998). Outcomes in neurological and neurosurgical disorders. Cambridge, UK: Cambridge University Press. p. 172. ISBN 0-521-44327-X.
•  Done Dodson, W. Edwin; Giuliano Avanzini; Shorvon, Simon D.; Fish, David R.; Emilio Perucca (2004). The treatment of epilepsy. Oxford: Blackwell Science. pp. 775-. ISBN 0-632-06046-8.{{cite book}}: CS1 maint: multiple names: authors list (link)

Chapter 64: Surgery of Post-Traumatic Epilepsy

•  Done Daniel L. Barrow (1992). Complications and sequelae of head injury. Park Ridge, Ill: American Association of Neurological Surgeons. pp. 127–132. ISBN 1-879284-00-6.

Chaptre 8: Post-Traumatic Epilepsy

Jennet's 1975 book ("Epilepsy after Non-Missile Injuries", 2nd Edition, 1975) appears to be the definitive work from which others are based. Its age means that some definitions may have been superseded. If you can get hold of this book, your articles would benefit immensely.

Temkin's 1990 study ("A randomized double-blind study of phenytoin for the prevention of post-traumatic seizures" N Engl J Med 323:497-502, 1990) seems to be the critical study into prophylaxis.

Jennet is responsible for the classification into early and late post-traumatic seizures, with the early form occurring with the first week. This definition still holds. Some have suggested a refinement to consider the first day as another threshold. Several sources state "One third of early seizures occur within the first hour of injury, another one-third within the first day, and the last one-third during the remainder of the first week"-- including bowen 1992 delldot talk 22:49, 6 March 2008 (UTC)

The Textbook Of Traumatic Brain Injury says "Technically, if seizures occur after the first week postinjury and are recurrent, the term post-traumatic epilepsy should be used, but the literature uses the terms posttraumatic seizures and posttraumatic epilepsy interchangeably, and most seem to favor the use of posttraumatic seizures.

I'd say we can classify post-traumatic seizures into two groups: early (within 7 days of injury) and late. The early group can be further subdivided such that immediate seizures occur within 24 hours of injury.

The issue is that if one has epilepsy, then one also has seizures. But one may have seizures without epilepsy (i.e., if they are provoked). It is safer for authors to use the term "seizures" since they are observable unambiguous events that may be counted and dated. The transition from saying "these seizures are caused by the original injury" (provoked) to "these seizures are due to the long-term brain damage" (unprovoked)" is the key to the use of the term "epilepsy". The "one week" threshold is, according to most, rather arbitrary. Your source for the provoked/unprovoked distinction is using the early=provoked late=unprovoked grouping in an approximate manner. They aren't directly equivalent due to the arbitrary nature of the 7 day cut-off.

• Hauser WA, Annegers JF, Kurland LT (1991). "Prevalence of epilepsy in Rochester, Minnesota: 1940-1980". Epilepsia. 32 (4): 429–45. PMID 1868801.{{cite journal}}: CS1 maint: multiple names: authors list (link)

(not free) This is the definitive epidemiological study of epilepsy, and the one where the 5% figure comes from.

• Garga N, Lowenstein DH (2006). "Posttraumatic epilepsy: a major problem in desperate need of major advances". Epilepsy Curr. 6 (1): 1–5. doi:10.1111/j.1535-7511.2005.00083.x. PMID 16477313.

This reports that one study suggests even a single late seizure should be a strong indication to initiate antiepileptic drug treatment. A few people define epilepsy as a propensity to recurrent seizures rather than have a history of recurrent seizures. That would effectively diagnose these people with epilepsy due to the injury + one seizure.

•  Done Chang BS, Lowenstein DH (2003). "Practice parameter: antiepileptic drug prophylaxis in severe traumatic brain injury: report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 60 (1): 10–6. PMID 12525711.

This is your expert report you need to give current best-practice recommendations on prophylaxis. They recommend prophylactic treatment with phenytoin for one week in cases of severe TBI. They discourage the routing use after 7 days, and make no recommendation for mild to moderate TBI. The paper also contains useful stats.

• Massagli T (1992). "Prophylaxis and treatment of posttraumatic epilepsy with phenytoin". West. J. Med. 157 (6): 663–4. PMID 1475952.

Written after Temkin's 1990 study, this confirms the tradition of one year of prophylaxis but recommends only one week.

• "Post-traumatic epilepsy". Br Med J. 2 (6132): 229. 1978. PMID 98198.

Written between Jennet and Temkin, this is somewhat dated. The stats on 7000 PTE cases per year in Britain are interesting. Without the benefit of later studies, the author's repeat a claim that "100,000 Americans develop epilepsy each year because they have not been given prophylactic anticonvulsants" and suggest it is "prudent to continue [anticonvulsants] for at least two years, after which the drug should be tailed off slowly".

This article contains an interesting quote from Wilder Penfield that the gap between injury and seizure is "a silent period of strange ripening". Might be worth repeating that.

• Jennett WB (1965). "Predicting epilepsy after blunt head injury". Br Med J. 1 (5444): 1215–6. PMID 14275018.

This paper by Jennett predates his 1975 book. The early/late distinction (one week) is present even then. He uses the word "epilepsy" in a way that wouldn't be allowed now (for example, to describe a single generalised convulsion one minute after injury). Epilepsy by definition is not provoked and must be recurrent. I think Jennett is the origin of the misuse of seizures/epilepsy terms. Many later author's have preferred to say "seizures" rather than use his words, leading to a mix of usage.

Colin 13:41, 25 February 2008 (UTC) (posted to User talk:Delldot)

The sources marked  Done I've already fully read. delldot talk 00:15, 4 March 2008 (UTC)

GA Review

This review is transcluded from Talk:Post-traumatic epilepsy/GA1. The edit link for this section can be used to add comments to the review.

Some comments as I go along reading this important article:

• Generally: Some of the reference URLs need updating (Blackwell Synergy is down, PubMedCentral now works with the pmc= parameter). JFW | T@lk 08:29, 25 July 2008 (UTC)

• I only found one that needed correcting, you must have gotten the PMC ones--thanks much! delldot talk 15:13, 25 July 2008 (UTC)

• Generally: WP:MEDMOS could be applied to the section titles and the section order. JFW | T@lk 12:40, 25 July 2008 (UTC)

• Changed "Definitions" to "Classification". I don't see anything out of order, although several are missing. Anything else needed? delldot talk 15:13, 25 July 2008 (UTC)

• No. It is the problem that I tend to deviate somewhat from MEDMOS... JFW | T@lk 15:41, 25 July 2008 (UTC)

• Generally: While not a requirement, some of the redlinks may have stub potential. JFW | T@lk 12:40, 25 July 2008 (UTC)

• I'm working on two in my userspace (epileptogenesis and primary and secondary injury), but have stalled on both of them because I'm having trouble writing about any aspects other than physical trauma, so I'm giving it undue weight. Certainly epileptic focus and Benjamin Winslow Dudley are good possibilities. I'll work on them in the next week. delldot talk 15:13, 25 July 2008 (UTC)

• Created Kindling model and mainspaceified Epileptogenesis. delldot talk 17:40, 28 July 2008 (UTC)
• Mainspaceified primary and secondary brain injury. delldot talk 12:08, 1 August 2008 (UTC)

• Intro: Does the intro need to contain so much information about the nomenclature of PTS vs PTE? Could this be moved to the article body ("Definition" section), with only a very basic definition remaining? JFW | T@lk 08:29, 25 July 2008 (UTC)

• Good idea! delldot talk 15:13, 25 July 2008 (UTC)

• Intro: The paragraph beginning with "Diagnostic measures" contains no references; while this is not strictly necessary, it would be nice. JFW | T@lk 08:29, 25 July 2008 (UTC)

• Some added, I can add more if you think it's a good idea. Oddly, I've been told in other articles that there's too much referencing in the lead and that the lead needs few or no refs because it's a summary of content referenced in the article. Personally, I'm more in favor of erring on the side of too much referencing though. delldot talk 15:55, 25 July 2008 (UTC)

• Hmm. A single reference should be available for each statement. If that isn't possible then usually the statement is not suitable for the lead :-). JFW | T@lk 16:47, 25 July 2008 (UTC)

• You mean the sentences should not need mid-sentence refs? Or that I should be able to find a single ref that covers all the statements? delldot talk 06:03, 26 July 2008 (UTC)

• Ideally the latter. You are right that I find mid-sentence refs a bit much for the intro. JFW | T@lk 07:23, 27 July 2008 (UTC)

• I don't know if I'm going to be able to find something that has all the points covered, so far a look through the reviews I've already used hasn't produced anything. I'll keep my eye out though. delldot talk 17:40, 28 July 2008 (UTC)

• Definitions: This section is generally a bit vague ("some definitions"). It is possible to generalise a bit here? JFW | T@lk 08:29, 25 July 2008 (UTC)

• I ended up rewriting a lot of this section, how is it now? There's still the vagueness because disagreement on the definitions exist, I'm afraid. delldot talk 23:20, 27 July 2008 (UTC)

• Characteristics: Rename "Signs and symptoms" per WP:MEDMOS? JFW | T@lk 08:29, 25 July 2008 (UTC)

• It doesn't really discuss signs and symptoms though, I'm not sure what the right name for this section could be. I could take the onset out and merge with some info from prognosis into a "Timing" section or something. The focal and generalized info could go into classification. delldot talk 15:55, 25 July 2008 (UTC)

• I'd say a seizure is a symptom... There is going to be some content that could go either in this section or in the prognosis/epidemiology sections. JFW | T@lk 16:47, 25 July 2008 (UTC)

• The seizure types info is now under classification. delldot talk 06:13, 26 July 2008 (UTC)

• Characteristics: Is it possible to capture short definitions of seizure terminology such as "partial" and "complex"? JFW | T@lk 08:29, 25 July 2008 (UTC)

• Thanks much for the help here. delldot talk 06:13, 26 July 2008 (UTC)

• Characteristics/Onset: Is this subsection needed? JFW | T@lk 08:29, 25 July 2008 (UTC)

• Maybe not, but I would like to keep the info on onset somewhere in the article since it's discussed in a lot of sources and it looks like an important area of study. Should it be incorporated into a "Timing" section or stuck into some other section? I don't know whether it would fit under prognosis: the question is how likely a person is to get PTE after a TBI and how much later. delldot talk 15:55, 25 July 2008 (UTC)

• I think the content is relevant, but is there a need to create a single subsection for it? JFW | T@lk 16:47, 25 July 2008 (UTC)

• It's under "Prognosis" now, I couldn't figure out where else to put it. I'm not sure if this is a logical place since it's got more to do with the prognosis of the TBI than the PTE. I can move it somewhere else if necessary. delldot talk 06:03, 26 July 2008 (UTC)

• Characteristics/Onset: "the number may be 80–90% or more" who does this apply to? JFW | T@lk 08:29, 25 July 2008 (UTC)

• Changed to At least 80–90% of people with PTE have their first seizure within two years of the TBI. -- is this clearer?

• OK. JFW | T@lk 15:41, 25 July 2008 (UTC)

• Pathophysiology: Section would benefit from some clarification of difficult terms (e.g. "excitotoxicity", "neurotransmitter"). Is there a secondary source that enumerates the different theories? What is the etymology of "kindling" in "kindling theory"? JFW | T@lk 12:40, 25 July 2008 (UTC)

• Terms explained, kindling theory etymology provided. I'll keep looking for the secondary source that covers the different theories. delldot talk 23:20, 27 July 2008 (UTC)

• I haven't had any luck finding a single source that covers everything in as much detail as I have here, but ref name="Mani06" mentions each topic. delldot talk 17:40, 28 July 2008 (UTC)

• Diagnosis: is CT actually used if MRI not diagnostic? Counter-intuitive, as MRI gives much higher definition. Sometimes CT is used if MRI shows a lesion that can't be determined, but if there is no lesion then CT is a waste of time. IMHO. Anyway. JFW | T@lk 12:40, 25 July 2008 (UTC)

• Whoops, yeah, didn't mean to imply CT would be more accurate. Rearranged wording to "CT scanning can be used to detect brain lesions if MRI is unavailable" certainly availability, not sensitivity, would be the reason for CT. delldot talk 15:13, 25 July 2008 (UTC)

• Diagnosis: do the sources make any mention of alternative causes for seizures after a head injury, such as medication use, metabolic disturbances (low sodium)? These may lead to seizures in any hospitalised patient without necessarily indicating a chronic seizure disorder. JFW | T@lk 12:40, 25 July 2008 (UTC)

• A couple sentences added here, let me know if more is needed. delldot talk 23:20, 27 July 2008 (UTC)

• Epidemiology: section could do with a bit more structure. I would ditch the single subheader, or alternatively introduce further headers. JFW | T@lk 12:40, 25 July 2008 (UTC)

• I've added level 4 headers, and I like how these break up the text more, but that still leaves a single level 3. Alternately I could do away with all the level 4's and the level 3, or create a separate level 2 for risk factors. delldot talk 23:20, 27 July 2008 (UTC)

• History: excellent content. JFW | T@lk 12:40, 25 July 2008 (UTC)

I will stop now, but hopefully I can carry on later on today. JFW | T@lk 08:29, 25 July 2008 (UTC)

 Done Have dome some copyediting myself and may come back to do some more. I'm sure there will be more comments after the above. JFW | T@lk 12:40, 25 July 2008 (UTC)

Sounds good, thanks so much for the thorough review and the work you've put in! I'll get to work on these today. delldot talk 15:13, 25 July 2008 (UTC)

By all means give me a yelp when you're done. I can then offer further comments or decide to promote :-). JFW | T@lk 15:41, 25 July 2008 (UTC)

Sounds good. Have to go now but I'll get back to work on these as soon as I can. Thanks for the great suggestions, sorry for the lackluster response. delldot talk 15:55, 25 July 2008 (UTC)

If this is a lacklustre response then I'm Jabba the Hutt. JFW | T@lk 16:47, 25 July 2008 (UTC)

Don't eat me! :P I'll keep working, but progress will likely be slow till after Monday. delldot talk 06:13, 26 July 2008 (UTC)

That's fine. I won't eat you. JFW | T@lk 07:23, 27 July 2008 (UTC)

Part II

Some further comments in anticipation of GA approval:

• Intro: I'm not sure if the definition of "symptomatic epilepsy" is that it is caused by a structural defect. JFW | T@lk 10:01, 29 July 2008 (UTC)

• Changed. delldot talk 15:14, 29 July 2008 (UTC)

• Classification: is there any way to generalise about the classification about PTS/PTE any further? The section appears to contradict itself a few times, if only because it calls on different sources. Has there been a consensus of any form? If there is, then perhaps more emphasis on this consensus is needed. JFW | T@lk 10:01, 29 July 2008 (UTC)

• Yeah, it's not actually nearly as complicated as I had made it sound: it's unprovoked that matters, timing is just a way to judge that. Hopefully the changes I made clear this up. I also added some info on the controversy over whether to diagnose PTE after one seizure or to require more than one. I can't find any consensus statement though, but that would be nice. delldot talk 17:36, 31 July 2008 (UTC)

• Pathophysiology: I have slightly rearranged the excitotoxicity material - revert me if I've made an error. JFW | T@lk 10:01, 29 July 2008 (UTC)

• Nope, it's fine. delldot talk 15:14, 29 July 2008 (UTC)

• Diagnosis: "any person is susceptible to seizures" - presumably this refers to people admitted to hospital after head trauma only. JFW | T@lk 10:01, 29 July 2008 (UTC)

• Actually I was trying to say that having head trauma doesn't protect you from seizures with other causes (e.g. metabolic), so seizures may not necessarily be due to TBI even in a TBI survivor (i.e. a diagnosis of PTE shouldn't be made just because a seizure occurs in a TBI survivor). Reworded, is this clearer? delldot talk 15:14, 29 July 2008 (UTC)

• It most certainly is. JFW | T@lk 15:27, 29 July 2008 (UTC)

• Diagnosis: "caregivers" - do you mean physicians? JFW | T@lk 10:01, 29 July 2008 (UTC)

• Generalized to include others (e.g. physician assistants). delldot talk 15:14, 29 July 2008 (UTC)

• OK (sorry, have bee in bonnet wrt this). JFW | T@lk 15:27, 29 July 2008 (UTC)

• Prevention: no comments. JFW | T@lk 10:01, 29 July 2008 (UTC)
• Treatment: is there any data at all about which anticonvulsant may be more effective in PTE? JFW | T@lk 10:04, 29 July 2008 (UTC)

• Info added. delldot talk 20:19, 30 July 2008 (UTC)

• Treatment: I had to look up "mesial" - short definition perhaps? JFW | T@lk 10:01, 29 July 2008 (UTC)

• Done delldot talk 20:19, 30 July 2008 (UTC)

• Prognosis: is it known why stroke appears more common in PTE? JFW | T@lk 10:01, 29 July 2008 (UTC)

• It's weird, I can't find that info again in the source (possibly because there are a couple pages I can't see in Google books). And I can't find it anywhere else either. I've taken it out. delldot talk 17:12, 31 July 2008 (UTC)

• Epidemiology: perhaps replace level 4 headers with "semicolon" headers to uncrowd the TOC? JFW | T@lk 10:01, 29 July 2008 (UTC)

• Done delldot talk 15:14, 29 July 2008 (UTC)

• Epidemiology: different statistics are quoted from different sources wrt the incidence of PTE after mild/moderate/severe head injury. A case for grouping all the figures somewhere? JFW | T@lk 10:01, 29 July 2008 (UTC)

• Sorry, I don't understand. delldot talk 15:14, 29 July 2008 (UTC)

• Checked again. It's fine. Never mind. JFW | T@lk 15:23, 29 July 2008 (UTC)

• Epidemiology: perhaps a 5-word clarification of standardized incidence ratio (as it is a redlink)? JFW | T@lk 10:01, 29 July 2008 (UTC)

• The best definition I could come up with for standardized incidence ratio was "a great deal of scary math stuff", but that was 7 words. Luckily, the original study had it in regular English too, so reworded in the article and changed the citation. delldot talk 20:24, 29 July 2008 (UTC)

• Excellent. JFW | T@lk 21:07, 29 July 2008 (UTC)

• Epidemiology: the numbers cited to Pitkänen et al are surely from a primary research study - perhaps add a direct reference to that study as well? JFW | T@lk 10:01, 29 July 2008 (UTC)

• Done delldot talk 15:14, 29 July 2008 (UTC)

• History: the section is mainly about surgery; are there any useful historical sources about non-surgical approaches? JFW | T@lk 10:01, 29 July 2008 (UTC)

• Paragraph added. delldot talk 17:12, 31 July 2008 (UTC)

That should be about it... JFW | T@lk 10:01, 29 July 2008 (UTC)

I've begun working, but progress will likely still be slow. delldot talk 15:14, 29 July 2008 (UTC)

Great stuff so far. Let me know when I can give this fine article the Green Blob. JFW | T@lk 15:22, 29 July 2008 (UTC)

I think I've addressed everything, let me know if I missed any. delldot talk 12:08, 1 August 2008 (UTC)

GA done. Good. JFW | T@lk 21:46, 2 August 2008 (UTC)

Classification

From the ILAE:

• YPartial (or Focal) – involves only part of one hemisphere of the brain. (or, more simply, involves only part of the brain)
• YGeneralised – involves both hemispheres of the brain.

A few comments on classification:

• YThe text on partial, "therefore part of the body", is too simplistic and assumes motor signs. A partial seizure might instead affect the senses, the autonomic nervous system, or the mind.
• YThe text on generalised, "leading to convulsions of the entire body", isn't always the case, as there are many other effects of generalised seizures and convulsions do not always occur. The "loss of consciousness" is correct, though it can be brief.
• Y"they may have a focal onset and then proceed to affect the entire body (a phenomenon known as "secondary generalization")" This uses the word "focal" without informing the reader that it is synonym for partial. It repeats the "entire body" (see point above). It might be simpler to just say that sometimes generalised seizures begin as partial seizures, which spread. The reader of this article probably doesn't need to have "secondary generalization" defined, unless you intend to use it again (e.g., in the epidemiology).
• Y"while partial seizures increase in prevalence as time passes after the injury" might be read to mean they become more common/frequent with time rather than become the more common form of seizure.

I would offer to revise the text here but it is getting late for me tonight, and I'd have to use different sources from yours. Colin°^Talk 21:31, 26 July 2008 (UTC)

Thanks much for the accuracy check Colin, I think these are fixed now. About the last point, neither the ref cited or the paper it cites is clear on which meaning: "[complex partial] and [partial with generalization] seizures are most common after the first week", says Barry E, Bergey GK, Krumholz A; et al. (1997). "Posttraumatic seizure types vary with the interval after head injury". Epilepsia. 38 (Supplement 8): 49S–50S. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)

Reading that, it looks like this info has more relevance to post-traumatic seizure anyway, since it's mainly covering the first week after TBI, so I'm going to take this info out.

Thanks again, your feedback is always most welcome. delldot talk 23:56, 26 July 2008 (UTC)

GA done. Congratulations. JFW | T@lk 21:45, 2 August 2008 (UTC)

Image

This article could use an image in the lead. Not sure what but... Doc James (talk · contribs · email) 03:02, 19 December 2009 (UTC)

Jennett's work

Chokseym added the following:

“ It is unlikely that the work of Jennett et al (1972)on the risk factors for post-traumatic epilepsy will be improved upon in the future, and all subsequent studies have merely confirmed their original findings. The principal risk factors in post-traumatic non-missile civilian head injury remain the presence of a penetrating injury with a dural tear, a haematoma, early epilepsy and PTA of > 24 hours. In the worst case scenario (all 4 factors) the risk is over 70%, falling to under 3% if none are present.(see Jennett B. Epilepsy after Non-Missile head injuries. Heinemann London 1975) ”

This may be true, except this is written in Wikipedia's voice without a source. I am sure that it is correct, but we cannot say it without a WP:MEDRS-compatible secondary source. JFW | T@lk 17:08, 25 February 2014 (UTC)