gms | German Medical Science

Objective: Posttraumatic epileptic seizures (PTS) are a serious complication in patients with subdural haematoma (SDH). However, to date, several studies have shown discordances about SDH-associated seizures in terms of incidence, risk factors and prophylactic antiepileptic treatment. The aim of this study was first to perform a systematic literature review of PTS in SDH and secondly to analyse incidence, risk factors of PTS and establish a guideline in patients with acute SDH (aSDH) to standardize the decision for prophylactic antiepileptic treatment.

Methods: A systematic literature review examining PTS in patients with SDH was performed using PubMed gateway, Cochrane Central Register of Controlled Trials, and Excerpta Medica dataBASE between September 1961 and February 2016. Search terms included subdural haematoma, seizure, epilepsy, prophylactic antiepileptic drugs, anticonvulsive medication, and risk factors. PRISMA statements were used for assessing data quality. Two independent reviewers extracted data from included studies and disagreement was solved by consensus. Furthermore a retrospective study with 139 aSDH patients treated from 2007 until 2015 were analysed. Baseline characteristics and clinical findings including Glasgow coma scale (GCS) at admission, 24 hours after operation, timing of operation, anticoagulation, Glasgow outcome scale (GOS) at hospital discharge and after 3 months were examined. Multivariate logistic regression analysis was performed to detect independent predictors of epileptic seizures and a scoring system was developed.

Results: In total, twenty-four studies were included into the study. Overall incidence of early PTS (ePTS) and late PTS (lPTS)/2years was 28% and 43% in aSDH whereas the incidence of e- and lPTS was lower in chronic SDH (cSDH; 5.3% vs. 10%). Similar incidence of ePTS in aSDH was found in our cohorts with 38%, preoperatively 15% and postoperatively 25%. 90% of patients with preoperative epileptic seizures were seizure-free after operation. Overall risk factors for PTS in patients with aSDH were: 24 hours postoperative Glasgow Coma Score (GCS) score below 9 (OR 10.5), craniotomy (OR 3.9), preoperative GCS below 8 (OR 3.1). In the retrospective study, independent predictors of PTS were also low GCS (<9; OR 3.3) 24 hours after operation and anticoagulation (OR 2.2). In patients with cSDH the risk factors were alcohol abuse (OR 14.3), change of mental status (OR 7.2), previous stroke (OR 5.3) and density of haematoma in computer tomography (OR 3.8). Age, sex, haematoma size/side and midline shifts were not significant risk factors for PTS in both types of SDH. In prevention of PTS phenytoin and levetiracetam showed similar efficacy (OR 1.3), whereas levetiracetam was associated with significantly lower adverse effects (OR 0.1). Additionally, a score system (GATE 24) was developed; cut-off was measured at 24 points. Patients with less than GCS 14, a prophylactic antiepileptic treatment is recommended.

Conclusion: PTS are a serious complication in patients with SDH, particularly in aSDH. Based on GATE 24-score, seizure prophylaxis should be considered in high-risked patient to promote better clinical outcome.