What is the management for a child with a history of seizures who has suffered a head contusion?

Management of Head Contusion in a Child with Pre-existing Seizure History

For a child with a history of seizures who sustains a head contusion, obtain urgent head CT to identify treatable intracranial pathology, initiate strict physical and cognitive rest for the first 3 days, and consider short-term antiepileptic prophylaxis (levetiracetam preferred) for the first 7 days if high-risk features are present (severe injury, intracranial hemorrhage, or subdural hematoma). 1, 2, 3

Initial Assessment and Imaging

Immediate head CT is the preferred imaging modality to identify acute intracranial hemorrhage, mass effect, or other treatable lesions that may require urgent surgical intervention. 1, 2

• CT identifies 100% of acutely treatable lesions in post-traumatic cases, with approximately 7% requiring urgent surgical intervention 1, 2
• Neuroimaging is particularly important in children with pre-existing seizure disorders, as it identifies those at greater risk for post-traumatic seizures 1
• MRI is more sensitive for detecting microhemorrhages and diffuse axonal injury but is less practical in the acute setting and should be reserved for delayed evaluation if symptoms persist 1

Risk Stratification for Post-Traumatic Seizures

Children with pre-existing seizure disorders require careful risk assessment, as certain injury characteristics dramatically increase seizure risk:

High-risk features include: 1, 2, 4, 5

• Severe head injury (Glasgow Coma Scale ≤8) - carries 35% seizure risk versus 5.1% in mild injury 4
• Presence of subdural hematoma 1, 4
• Diffuse cerebral edema 4, 5
• Open depressed skull fracture with parenchymal damage 4
• Age less than 3 years 5
• Intracranial hemorrhage 4, 6

Early post-traumatic seizures (within 7 days) occur in 94.5% of cases within the first 24 hours after injury, making immediate prophylaxis critical in high-risk patients. 4, 5

Antiepileptic Prophylaxis Decision Algorithm

For children with high-risk features (listed above), initiate levetiracetam prophylaxis for 7 days: 2, 7

• Levetiracetam is strongly preferred over phenytoin due to better tolerability and avoidance of excess morbidity 2
• Dosing for children ages 4-16 years: Start 20 mg/kg/day divided twice daily (10 mg/kg BID), may increase by 20 mg/kg increments every 2 weeks to maximum 60 mg/kg/day 7
• Prophylactic antiepileptic drugs should not be continued beyond 7 days unless the child develops actual seizures, as prolonged prophylaxis does not prevent late post-traumatic epilepsy and may worsen cognitive outcomes 2, 8

For children without high-risk features, prophylactic antiepileptics are not routinely recommended, but close neurological monitoring is essential. 2

Immediate Post-Injury Management (First 3 Days)

Implement strict physical and cognitive rest during the first 3 days after injury, regardless of apparent injury severity: 1, 3

• Limit screen time, reading, and cognitively demanding activities 3
• Keep the child home from school 3
• Avoid all sports and physical exertion 3
• Children who start rest immediately recover 4.6 days sooner than those who delay rest 3

Warning Signs Requiring Emergency Re-evaluation

Educate families to monitor for red flag symptoms: 1, 9

• Severe or worsening headache (manifested as inconsolable crying in young children) 9
• Clear or bloody fluid draining from nose or ears 9
• Seizure activity (particularly important given pre-existing seizure history) 1
• Altered mental status or decreased level of consciousness 1
• Persistent vomiting 1
• Balance problems or difficulty with normal motor activities 9

Gradual Return to Activity Protocol (After Day 3)

Following the initial 3-day strict rest period, implement a stepwise return to activity that does not exacerbate symptoms: 1, 3

1. Light cognitive activity - brief periods of reading, light homework 1, 3
2. Light aerobic activity - walking, light jogging 1, 3
3. School reintegration - gradual increase in academic workload 1, 3
4. Sport-specific exercise - only after symptom-free at rest and with exertion 1, 3

If symptoms worsen at any stage, return to the previous level for 24 hours before attempting progression again. 3

Follow-Up Schedule

Arrange follow-up within 3-5 days to reassess symptoms and adjust the activity plan. 3

• Earlier follow-up is needed if symptoms worsen, new symptoms develop, sleep disturbances persist, or symptoms continue beyond 2 weeks 3
• Most children's symptoms resolve within 1-3 months, but close monitoring is essential during the first 4-6 weeks 1, 9
• For children with symptoms persisting beyond 4-6 weeks, provide or refer for appropriate specialized assessments and interventions 1

School Reintegration Considerations

Medical and school-based teams should collaborate on return-to-school protocols: 1

• Gradually increase duration and intensity of academic activities as tolerated without significantly exacerbating symptoms 1
• Customize protocols based on severity of postconcussion symptoms 1
• For prolonged symptoms interfering with academic performance, assess need for educational supports under federal statutes (Individuals With Disabilities Education Act §504) 1

Critical Pitfall to Avoid

Do not continue antiepileptic prophylaxis beyond 7 days in the absence of actual seizures, as this does not prevent late post-traumatic epilepsy and may cause adverse cognitive effects that worsen recovery outcomes. 2, 8 The child's pre-existing seizure disorder should continue to be managed with their baseline antiepileptic regimen as prescribed by their neurologist.