What is the role of methylprednisolone in cases of seizures following a hanging injury?

Methylprednisolone Should Not Be Used for Seizures Following Hanging Injuries

High doses of systemic corticosteroids, including methylprednisolone sodium succinate, should not be used for the treatment of seizures following hanging injuries due to increased mortality risk and lack of evidence supporting their use. 1

Pathophysiology and Management of Seizures After Hanging

• Seizures following hanging are likely due to hypoxic-ischemic brain injury, which can lead to status epilepticus in some cases 2
• First aid management for seizures should include:
  • Activating emergency medical services immediately 3
  • Helping the person to the ground and placing them in the recovery position 3
  • Clearing the area around them to prevent injury 3
  • Staying with the person until emergency services arrive 3

Evidence Against Methylprednisolone Use

• FDA labeling specifically warns against using high-dose corticosteroids for traumatic brain injury, noting increased early (2 weeks) and late (6 months) mortality in patients with cranial trauma 1
• A randomized, placebo-controlled study showed increased mortality in patients with cranial trauma treated with methylprednisolone hemisuccinate who did not have other clear indications for corticosteroid treatment 1
• The 2018 guidelines for management of severe traumatic brain injury explicitly state: "We do not recommend using high-dose glucosteroids after severe TBI" (Grade 1-, Strong Agreement) 3

Recommended Treatment Approach for Post-Hanging Seizures

Acute Management

• For active seizures, standard antiepileptic medications should be used 3:
  • Sodium valproate, levetiracetam, phenytoin, benzodiazepines, propofol, or barbiturates 3
  • For myoclonic seizures specifically, propofol, clonazepam, sodium valproate, or levetiracetam may be effective 3

Ongoing Management

• Prophylactic antiepileptic drugs are not routinely recommended for prevention of post-traumatic seizures 4, 5
• If antiepileptic medication is considered necessary due to specific risk factors:
  • Levetiracetam is preferred over phenytoin due to better tolerability and fewer drug interactions 4, 5
  • Treatment duration should be limited to 7 days unless there are specific risk factors for delayed seizures 5

Risk Factors for Post-Traumatic Seizures

• Early post-traumatic seizures (within 7 days) occur in approximately 2.2% of all traumatic brain injury cases 4
• Risk factors that may warrant closer monitoring include:
  • Loss of consciousness or amnesia for more than 24 hours 4
  • Age over 65 years 4
  • Presence of intracranial hemorrhage 4, 5
  • Craniectomy 4

Monitoring Recommendations

• Continuous EEG monitoring should be considered in patients with depressed mental status disproportionate to their brain injury to detect subtle seizure activity 5
• Head CT is the preferred initial imaging modality to identify acute intracranial hemorrhage or mass effect that may require urgent intervention 5

Important Caveats

• While some case reports suggest potential benefit of methylprednisolone in refractory epilepsy in children 6, 7, these findings cannot be extrapolated to traumatic seizures following hanging injuries
• The increased mortality risk associated with high-dose corticosteroids in traumatic brain injury outweighs any potential benefit in seizure control 1, 3
• Seizures following hanging require prompt neurological assessment and standard antiepileptic treatment approaches rather than corticosteroid therapy 3