Rationale:
Post-traumatic seizures (PTS) are a known complication of moderate to severe traumatic brain injury (TBI) and may evolve into post-traumatic epilepsy (PTE). Optimizing outcomes requires appropriate diagnostic testing, anti-seizure medication (ASM) management, and consistent follow-up (FU). However, limited data exist regarding factors that influence seizure outcomes in PTE.
Methods:
We conducted a review of an institutional new-onset seizure (NOS) patient database from 2021 to 2025. Patients were included if they had NOS attributed to TBI and at least one year of FU at a neurology clinic. Collected data included seizure frequency, ASM use, electroencephalogram (EEG) and imaging findings, and visit history.
Results:
Of 1,508 patients with NOS, 117 (7.76%) were attributed to TBI. Forty-five met inclusion criteria for ≥ 1 year of FU. FU ranged from 1 to 2 years (1–11 visits; median: 4). Time to first FU ranged from 2 to 428 days (median: 41).
Seizure Freedom:
At last FU, 32 / 45 patients (71%) were seizure-free, defined as not having reported any seizures in their last FU visit. Four patients (8.9%) were seizure-free and off ASM. Of the 13 remaining, one experienced monthly seizures, and 12 had < 1 seizure / month. Patients seen in FU within 41 days of onset had higher reported seizure freedom (74%) than those seen after the 41 days (68%).
ASM Initiation and Outcomes:
ASM was initiated in 38 / 45 patients (84%), typically during emergency department or inpatient encounters. ASM was later discontinued in three patients—one of whom had recurrence requiring reinitiation of ASM. Among the seven who were not started on ASM initially, only two remained seizure-free; remaining 5 were started on ASM at a FU visit.
Levetiracetam (LEV) was the most common initial ASM in 32 patients (71%) but was discontinued in 17 (53%) due to side effects. At last FU, 28 patients (62%) were on monotherapy, with 75% of this population reporting no seizures. LEV remained the most prescribed ASM (n=17), with an 82% seizure freedom rate. Among patients on ≥ 2 ASMs (n=11), seizure freedom was lower (63%).
Neuroimaging and EEG Findings:
Abnormal imaging was found in 21 patients (46%), and abnormal EEG in 22 (48%). Seizure freedom among those with abnormal imaging or EEG was similar to those with normal studies (76.1% vs. 77.7%). However, patients whose EEG was deferred, but later found to be abnormal, had lower rate of seizure freedom (40%).
Conclusions:
In this study of TBI-related new-onset seizures, most patients achieved seizure freedom with continued ASM use, though only 8.9% were seizure free off of ASMs at last FU. Patients with early FU were observed to have better outcomes, suggesting a potential benefit to timely outpatient follow-up. LEV demonstrated favorable seizure control, though side effects led to frequent discontinuation. Imaging findings were not aligned with seizure outcomes; poorer outcomes were observed when EEGs were deferred.
These findings highlight the importance of early neurologic evaluation, imaging and EEG in TBI-related seizures. They also demonstrate the potential of this database to establish factors that influence long-term post-traumatic seizure outcomes.
Funding: None