Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
Departments of Pediatrics, University of Michigan, Ann Arbor, Michigan.
Pediatr Neurol. 2022 Jan;126:114-119. doi: 10.1016/j.pediatrneurol.2021.10.009. Epub 2021 Oct 19.
Prophylactic antiseizure medications (ASMs) for pediatric traumatic brain injury (TBI) are understudied. We evaluated clinical and radiographic features that inform prescription of ASMs for pediatric TBI. We hypothesized that despite a lack of evidence, levetiracetam is the preferred prophylactic ASM but that prophylaxis is inconsistently prescribed.
This retrospective study assessed children admitted with TBI from January 1, 2017, to December 31, 2019. TBI severity was defined using Glasgow Coma Scale (GCS) scores. Two independent neuroradiologists reviewed initial head computed tomography and brain magnetic resonance imaging. Fisher exact tests and descriptive and regression analyses were conducted.
Among 167 children with TBI, 44 (26%) received ASM prophylaxis. All 44 (100%) received levetiracetam. Prophylaxis was more commonly prescribed for younger children, those with neurosurgical intervention, and abnormal neuroimaging (particularly intraparenchymal hematoma) (odds ratio = 10.3, confidence interval 1.8 to 58.9), or GCS ≤12. Six children (13.6%), all on ASM, developed early posttraumatic seizures (EPTSs). Of children with GCS ≤12, four of 17 (23.5%) on levetiracetam prophylaxis developed EPTSs, higher than the reported rate for phenytoin.
Although some studies suggest it may be inferior to phenytoin, levetiracetam was exclusively used for EPTS prophylaxis. Intraparenchymal hematoma >1 cm was the single neuroimaging feature associated with ASM prophylaxis regardless of the GCS score. Yet these trends are not equivalent to optimal evidence-based management. We still observed important variability in neuroimaging characteristics and TBI severity for children on prophylaxis. Thus, further study of ASM prophylaxis and prevention of pediatric EPTSs is warranted.
预防性抗癫痫药物（ASM）在小儿创伤性脑损伤（TBI）中的应用研究较少。我们评估了影响小儿 TBI 患者 ASM 处方的临床和影像学特征。我们假设，尽管缺乏证据，但左乙拉西坦是首选的预防性 ASM，但预防用药并不一致。
本回顾性研究评估了 2017 年 1 月 1 日至 2019 年 12 月 31 日期间因 TBI 入院的儿童。TBI 严重程度采用格拉斯哥昏迷量表（GCS）评分来定义。两名独立的神经放射科医生对初始头部 CT 和脑磁共振成像进行了复查。采用 Fisher 确切检验和描述性及回归分析。
在 167 例 TBI 患儿中，有 44 例（26%）接受了 ASM 预防治疗。所有 44 例（100%）均使用左乙拉西坦。年龄较小、接受神经外科干预、神经影像学异常（尤其是脑实质血肿）（比值比=10.3，95%置信区间为 1.8 至 58.9）或 GCS≤12 的患儿更常接受预防治疗。6 例（13.6%）接受 ASM 治疗的患儿发生了早期创伤后癫痫发作（EPTS）。在 GCS≤12 的患儿中，17 例接受左乙拉西坦预防治疗的患儿中有 4 例（23.5%）发生 EPTS，高于报告的苯妥英钠发生率。
尽管一些研究表明左乙拉西坦可能不如苯妥英钠，但它仍是 EPTS 预防的唯一选择。无论 GCS 评分如何，脑实质血肿＞1cm 是与 ASM 预防相关的唯一神经影像学特征。然而，这些趋势并不等同于最佳的循证管理。我们仍然观察到接受预防治疗的儿童的神经影像学特征和 TBI 严重程度存在重要差异。因此，有必要进一步研究 ASM 预防和预防小儿 EPTS。
