What is the best management for a 2-year-old girl with post-traumatic seizures (seizures triggered by a traumatic head injury), with normal initial computed tomography (CT) scan results?

Management of Post-Traumatic Seizures in a 2-Year-Old Girl

For a 2-year-old girl with multiple seizures following traumatic head injury and normal initial CT scan, the best management approach is to initiate MRI imaging to detect subtle brain injuries not visible on CT, followed by antiepileptic drug therapy with levetiracetam starting at 10-20 mg/kg twice daily. 1, 2

Diagnostic Approach

Imaging Considerations

1. MRI Brain:

   • While CT is appropriate for initial evaluation of trauma, MRI is superior for detecting subtle traumatic brain injuries that may cause seizures
   • MRI has higher sensitivity for detecting intracranial hemorrhage, micro-hemorrhage, parenchymal injury, and diffuse axonal injury 1
   • Sequences such as susceptibility-weighted imaging and diffusion-weighted imaging are particularly helpful in identifying diffuse axonal injury not apparent on CT 1

2. Timing of MRI:

   • Although initial CT was normal, the multiple seizures within a short timeframe warrant further investigation
   • MRI should be performed when the child is stable, as it provides better delineation of post-traumatic sequelae including gliosis and volume loss 1
   • Not recommended to be performed emergently unless clinical deterioration occurs 1

Other Diagnostic Considerations

• EEG monitoring should be considered to detect subclinical seizures, especially given the young age and multiple seizure events 1
• Young age (2 years) is an independent predictor for development of post-traumatic seizures 1

Treatment Approach

Pharmacological Management

1. Antiepileptic Drug Therapy:

   • Initiate antiepileptic medication given the recurrent nature of seizures (3 seizures within 2 weeks) 2, 3
   • Levetiracetam is preferred for pediatric post-traumatic seizures:
     • Starting dose: 10-20 mg/kg twice daily 2
     • Can be titrated up to approximately 60 mg/kg/day divided twice daily based on response and tolerability 2, 4
     • Has demonstrated safety and tolerability in pediatric TBI populations 4

2. Duration of Treatment:

   • Initial treatment duration of at least 30 days 4
   • Reassess need for continued therapy based on:
     • EEG findings
     • Presence of ongoing seizures
     • Resolution of acute post-traumatic changes

Monitoring and Follow-up

1. Neurological Monitoring:

   • Regular neurological assessments to detect changes in mental status
   • Monitor for medication side effects (most common with levetiracetam: headache, fatigue, drowsiness, irritability) 4

2. Follow-up Schedule:

   • Neurology consultation within 1-2 weeks
   • Follow-up MRI in 4-6 weeks if seizures persist
   • EEG monitoring if seizures continue despite medication

Special Considerations

Risk Factors for Post-Traumatic Epilepsy

• Young age (2 years) significantly increases risk 5
• Multiple seizures within short timeframe (3 seizures in 2 weeks) indicates higher risk for epilepsy development 1, 5
• Early post-traumatic seizures increase risk of late seizures (epilepsy) 6

Pitfalls to Avoid

1. Do not rely solely on normal CT findings to rule out significant brain injury - CT may miss subtle injuries that can cause seizures 1
2. Do not delay antiepileptic treatment given the recurrent nature of seizures and young age 5
3. Avoid phenytoin as first-line therapy - levetiracetam has better side effect profile in children 4, 3
4. Do not perform unnecessary repeat CT scans - MRI is more appropriate for follow-up 1

Prognosis

• Children with early post-traumatic seizures have worse outcomes than those without seizures 5
• Young children (under 3 years) with post-traumatic seizures have higher risk of poor outcomes 5
• Early intervention may improve long-term neurological outcomes and reduce risk of post-traumatic epilepsy 4