Delayed Effects Of Head Injury

POST-TRAUMATIC EPILEPSY

Early epilepsy (occurring within the first week from injury) Early epilepsy occurs in 5% of patients admitted to hospital with non-missile (i.e. deceleration) injuries. It is particularly frequent in the first 24 hours after injury. Focal seizures are as common as generalised seizures. Status epilepticus occurs in 10%. The risk of early epilepsy is high in

- children under 5 years.

- patients with prolonged post-traumatic amnesia

- patients with an intracranial haematoma

- patients with a compound depressed fracture. Late epilepsy (occurring after the first week from injury)

Late epilepsy also occurs in about 5% of all patients admitted to hospital after head injury. It usually presents in the first year, but in some the first attack occurs as long as 10 years from the injury. Usually seizures are generalised, but temporal lobe epilepsy (complex partial seizures) occurs in 20%. Late epilepsy is prevalent in patients with

- intracranial haematoma (35%)

- compound depressed fracture (17%). Prophylactic anticonvulsants appear to be of little benefit in preventing the development of an epileptogenic focus. Management is discussed on page 98.

CEREBROSPINAL FLUID (CSF) LEAK

After head injury a basal fracture may cause a fistulous communication between the CSF space and the paranasal sinuses or the middle car. Profuse CSF leaks (rhinorrhoea or otorrhoea) are readily detectable, but brain may partially plug the defect and the leak may be minimal or absent. Patients risk developing meningitis particularly in the first week, but in some this occurs after several years. When this is associated with anterior fossa fractures, it is usually pneumococcal; when associated with fractures through the petrous bone, a variety of organisms may be involved.

Clinical signs of a basal fracture have previously been described (page 218). The patient may comment on a 'salty taste' in the mouth. Anosmia suggests avulsion of the olfactory bulb from the cribriform plate.

Management

CSF leak - CSF leak continues or

| ^ X-rays show extensive

Observe*

Observe* disruption of the anterior fossa

CSF leak stops DURAL REPAIR

Head injury —* Signs of basal fracture |

| discharge

Observe*

Late attack of meningitis

* A recent Working Party concludcd that evidence does not support the use of prophylactic antibiotics (Lancct (1994) 344:1547-230 1551). Prophylactic antibiotics only cncouragc resistance and late attacks of meningitis may still occur despite incir use.

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