Abstracts

Rationale: Traumatic brain injury (TBI) is the number one cause of mortality and morbidity in the pediatric population. In moderate to severe pediatric abusive head trauma (AHT) there is a high risk of early post-traumatic seizures. However, most patients with AHT are only monitored clinically for seizures. Current treatment guidelines recommend prophylactic anti-seizure drugs in children with severe AHT. The temporal electrographic evolution of seizures after AHT is unclear as most children are not routinely monitored with continuous video EEG. We evaluated the overall seizure burden of AHT children by incorporating prospective, standardized cEEG monitoring. Methods: Children (age 1 month-18 years), admitted to the pediatric ICU at Children's Hospital Colorado, from 8/2009 through 6/2012 with moderate to severe traumatic brain injury, both accidental and non-accidental, received an institution-wide cEEG protocol for TBI reviewed by epileptologists, and were also prospectively enrolled in an IRB approved database. Twenty-eight children were identified with AHT based on clinical history, head imaging, presence of retinal hemorrhages, fractures, and by consultation with the child abuse prevention team. Complete EEG data was available for 15/28 patients. Most children were monitored via cEEG for a minimum of 48 hours. This data was re-reviewed by the authors for details about seizure onset, duration, presence of clinical signs, and seizure burden (amount of time occupied by seizure per hour of recording). Results: The 15 patients with AHT and complete EEG data ranged in age from 1-9 months and 10 (67%) were male. All but 2 (13%) were treated prophylactically with anti-seizure drugs. Nine AHT patients (60%) were identified as having electrographic seizures on cEEG. The median number of seizures was 57 (range 6 - 479). Between 64% and 100% of electrographic seizures were subclinical (median 93%). Of the 6/15 patients without electrographic seizures, 3 presented with clinical seizures (50%). All but one patient survived (93%). Two of the 9 patients (22%) with electrographic seizures developed seizures after 24 hours, but within 48 hours of monitoring. Five patients (56%) continued to have seizures beyond 48 hours post-injury. Seven of 9 patients (78%) with electrographic seizures developed at least one episode of status epilepticus (SE), and 5 (56%) had more than 1 episode of SE which was defined as greater than 50% of ictal activity in any hour of recording. Four patients (44%) developed SE after 24 hours of EEG recording. Conclusions: AHT infants had a high rate of seizures and status epilepticus, most of which were subclinical, detected only by cEEG monitoring. Our data supports the importance of routine cEEG monitoring in order to identify electrographic seizures and status epilepticus in AHT patients. A minimum of 48 hours of cEEG monitoring is recommended to screen for electrographic seizures.