What is the best management for an 11-year-old child with seizures (fits) after a history of head trauma 2 weeks ago?

Management of Post-Traumatic Seizures in an 11-Year-Old Child

CT imaging should be performed urgently to identify treatable intracranial lesions, as CT can identify 100% of acutely treatable lesions in patients with post-traumatic seizures, with 7% requiring urgent surgical intervention. 1

Initial Assessment and Imaging

• Head CT is the preferred initial imaging modality for post-traumatic seizures, especially to identify acute intracranial hemorrhage or mass effect that may require urgent intervention 1
• In a study of patients with mild trauma, CT identified all acutely treatable lesions, with 7% of patients having lesions requiring urgent surgical intervention despite 53% having negative CT results 1
• Neuroimaging allows detection of treatable pathology associated with intracranial trauma and identifies children at greater risk for seizures 1

Management Algorithm

Step 1: Immediate Imaging

• Perform urgent head CT to identify potential surgical lesions 1
• If CT shows mass effect, midline shift, or significant hemorrhage requiring evacuation, surgical intervention (option B: burr hole or more extensive surgery) may be necessary 2

Step 2: Based on CT Findings

If CT shows significant intracranial pathology requiring intervention:

• Surgical management (burr hole or craniotomy) for evacuation of hematoma with mass effect 2
• Post-surgical management should include:
  • Antiepileptic medication (levetiracetam preferred over phenytoin due to better tolerability) 1, 3
  • Serial neurological examinations 1
  • Follow-up imaging to assess resolution 1

If CT shows intracranial pathology not requiring immediate intervention:

• Serial brain CT scans (option C) to monitor evolution of intracranial lesions 1
• Antiepileptic medication (levetiracetam) for seizure control 3
• For children 4-16 years, levetiracetam dosing starts at 20 mg/kg/day in two divided doses, titrated up to 60 mg/kg/day 3

If CT is negative:

• Conservative management (option A) with close monitoring 1
• Consider antiepileptic medication if seizures persist 3
• Follow-up imaging with MRI may be beneficial to detect subtle abnormalities not visible on CT 1

Evidence for Specific Management Options

A. Conservative Management

• Appropriate for patients with negative CT findings or minor abnormalities without mass effect 1
• Should include antiepileptic medication if seizures have occurred 3
• Close monitoring for neurological deterioration is essential 1

B. Burr Hole

• Indicated only if CT shows a surgically treatable lesion such as epidural or subdural hematoma with mass effect 2
• Should not be performed without imaging confirmation of a surgical lesion 1

C. Follow-up with Serial Brain CT

• Appropriate for patients with intracranial pathology that doesn't require immediate surgical intervention 1
• Allows monitoring of evolution of traumatic lesions 1
• Should be performed at intervals determined by clinical status and initial CT findings 1

D. Mannitol Infusion

• Not routinely recommended in pediatric post-traumatic seizures without evidence of increased intracranial pressure 1
• Should be reserved for cases with confirmed increased intracranial pressure not responding to other measures 1

Important Considerations

• Risk factors for post-traumatic seizures in children include presence of subdural hematoma and young age 1, 4
• Early seizures (within 7 days) occur in 2.2% of TBI cases, but incidence is higher in severe TBI 1
• MRI may be more sensitive than CT for detecting microhemorrhages and diffuse axonal injury but is less practical in the acute setting 1
• Prophylactic antiepileptic drugs are not routinely recommended for prevention of post-traumatic seizures but may be considered in high-risk cases 1
• Levetiracetam is preferred over phenytoin due to better tolerability profile 1

Pitfalls to Avoid

• Performing surgical intervention without appropriate imaging 1
• Failing to identify surgically treatable lesions that require urgent intervention 1
• Overlooking the need for serial imaging in patients with abnormal initial CT findings 1
• Using prophylactic antiepileptic drugs without clear indication 1
• Relying solely on CT when MRI may provide additional valuable information in the subacute phase 1