Seizure prophylaxis in mild and moderate TBI tied to reduced risk of early posttraumatic seizures: JAMA

The researchers suggest weighing the small absolute risk reduction against the risks of prescribing antiseizure medications. The findings were published online in JAMA Neurology on April 8, 2024.

“The absolute risk reduction of seizure prophylaxis for early PTS was 0.6% in mild and moderate traumatic brain injury,” the researchers reported. The overall rate of early posttraumatic seizures was low, ranging from 0% to 4%.

Traumatic brain injury is one of the leading causes of disability and death worldwide. Posttraumatic seizures contribute to secondary brain damage after TBI and are tied to increased hospital length of stay, mortality, and worse functional outcomes. Guidelines recommend seizure prophylaxis for early PTS after severe TBI. The use of antiseizure medications for early seizure prophylaxis after mild or moderate TBI remains controversial.

Against the above background, Matthew Pease, Indiana University School of Medicine, Indianapolis, and colleagues aimed to determine the association between seizure prophylaxis and risk reduction for early PTS in mild and moderate TBI.

For this purpose, the researchers systematically searched the online databases from 1991 to 2023. They included observational studies of adult patients presenting to trauma centers in high-income countries with mild (Glasgow Coma Scale [GCS], 13-15) and moderate (GCS, 9-12) TBI comparing rates of early posttraumatic seizures among patients with seizure prophylaxis with those without seizure prophylaxis.

The main outcome was absolute risk reduction of early PTS, defined as seizures within seven days of initial injury, in patients with mild or moderate TBI receiving seizure prophylaxis in the first week after injury. In patients with only mild TBI, a secondary analysis was performed.

Following were the key findings:

• The researchers reviewed 64 full articles after screening; they included eight studies (including 5637 patients) for the mild and moderate TBI analysis and five studies (including 3803 patients) for the mild TBI analysis.
• The absolute risk reduction of seizure prophylaxis for early PTS in mild to moderate TBI (GCS, 9-15) was 0.6%.
• The absolute risk reduction for mild TBI alone was similar to 0.6%.
• The number needed to treat to prevent 1 seizure was 167 patients.

The systematic review and meta-analysis of cohort studies indicate that seizure prophylaxis may effectively prevent early PTS for mild and moderate TBI, with an absolute risk reduction of 0.6%.

“Practitioners should weigh low prevalence of early PTS and low-risk reduction against risks of antiseizure medicine, including inappropriate long-term continuation,” the researchers wrote.

Reference:

Pease M, Mittal A, Merkaj S, et al. Early Seizure Prophylaxis in Mild and Moderate Traumatic Brain Injury: A Systematic Review and Meta-Analysis. JAMA Neurol. Published online April 08, 2024. doi:10.1001/jamaneurol.2024.0689