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Traumatic Brain Injury (TBI) and Post Traumatic Epilepsy (PTE) in Veterans

Personnel with wartime injuries have a higher incidence of missile wounds and blast injuries, both of which may cause severe impairments. TBI disrupts the normal function of the brain and is caused by a bump, blow, jolt, exposure to loud noise or a penetrating head injury.  The majority of TBIs experienced in Iraq and Afghanistan are due to a blast-related injury. TBI may lead to Post Traumatic Epilepsy (PTE), a seizure disorder

 

PTE is also often associated with:

  • Skull fractures

  • Subdural hematomas (accumulation of blood between the brain and the skull, caused by a ruptured blood vessel)

  • Intracranial hematomas/hemorrhages

  • Brain contusion (bruise)

Diagnosing Epilepsy and Treatments

Diagnosing Epilepsy

Special Consideration for the Military: Military personnel may underreport mild TBI to avoid removal from combat situations or active duty and therefore may automatically be under diagnosed.  Also, limited time and resources available at forward medical commands can prohibit thorough TBI evaluation, which results in service members returning to duty with symptoms of an undiagnosed TBI. Diagnosing epilepsy is a multi-step process, usually involving the following evaluations:

  • Confirming through patient history, neurological exams, and supporting blood and other clinical tests – that the patient has epileptic seizures and not some other type of episode, such as fainting, transient ischemic attacks, hypoglycemia or non-epileptic seizures.

  • Identifying the type of seizure involved.

  • Performing a clinical evaluation in search of the cause of the epilepsy.

  • Selecting the most appropriate therapy based on all previous findings.


Doctor’s Investigation

If you’ve had a seizure, your doctor will look to answer these questions 

  • Was the seizure caused by a short-term problem (like fever or infection) that can be corrected?

  • Was it caused by a continuing problem in the way your brain’s electrical system works?

  • Is there anything about the structure of your brain that could cause seizures?

  • Was the seizure an isolated event, or does it mean that you have epilepsy?


Diagnostic Methods and Tools

The doctor’s main tool in diagnosing epilepsy is a careful medical history with as much information as possible about what the seizures look like and what happened just before they began. The doctor will also perform a thorough physical examination, especially of the nervous system.

Other Diagnostic Tools

An electroencephalograph (EEG) is a machine that records brain waves picked up by tiny wires taped to the head.  Electrical signals from brain cells are recorded as wavy lines by the machine.  Brain waves during or between seizures may show special patterns that can help the doctor decide whether or not someone has epilepsy, or is at risk for epileptic seizures.  A normal baseline EEG does not rule out the possibility of an underlying epileptic disorder.  Imaging methods such as computerized tomography (CT) or magnetic resonance imaging (MRI) scans may be used to search for any growths, scars, or other physical conditions in the brain that may be causing the seizures.  There are numerous other tests that can be performed to analyze the area of the brain causing seizures, but most of these are only done when a patient is being evaluated for possible epilepsy surgery.  Which tests and how many are ordered vary, depending on how much each test reveals.

Treatment Options

Treating epilepsy involves many different people. The team may include your primary care doctor, nurse, psychologist or social worker, and specialists such as a neurologist. You may want to bring along a family member or friend to help describe your seizures or to take notes during visits to your doctor. Once the doctor has made a diagnosis of seizures or epilepsy, the next step is to select the best form of treatment. If epilepsy – that is, a continuing tendency to have seizures – is diagnosed, the doctor will usually prescribe regular use of seizure-preventing drugs. If drugs are not successful, other methods are considered, including surgery, a special diet or vagus nerve stimulation (VNS). The goal of all epilepsy treatment is to prevent further seizures, avoid side effects, and make it possible for people to lead active lives.

Medication

Medications do not cure epilepsy but, for many, the medication will prevent seizures as long as they are taken regularly.  Most epilepsy medicines are taken by mouth.  The doctor’s and patient’s choice of which drug to consider depends on what kind of seizure a person is having.  Other factors include patient’s age, other medications, other medical problems, allergies and potential side effects of the medication. Some people experience side effects, while others may not.  It may take some time to find exactly the right dose of the right drug.  It is reported that antiepileptic drugs provide complete control for more than half of all patients with epilepsy, and significantly reduce the number of seizures in another 20-30 percent.  The remaining 20 percent do not respond to current medications and must look at other treatment options.

Surgery

When antiepileptic drugs fail to control or substantially reduce seizures, brain surgery may be considered.  Surgical removal of seizure-producing areas of the brain has been an accepted form of treatment for more than 50 years.  Some seizure medications may have to be continued, usually for a year or two.  Then, if no further seizures occur, the medicine may be slowly withdrawn.  At this point, chances of living free of seizures and free of medication are good.  However, many people will have to continue with medication and some do not benefit significantly from surgery.
 

Vagus Nerve Stimulation (VNS)

VNS is a type of treatment in which short bursts of electrical energy are directed into the brain via the vagus nerve, a large nerve in the neck which connects to the brainstem. The energy comes from a battery, about the size of a silver dollar, which is surgically implanted under the skin, usually on the left side of the chest.  Although complete seizure control is rarely achieved, the majority of people who use VNS therapy experience fewer seizures. In some, its effectiveness increases with time, and patients report an improved quality of life. It will almost always be necessary to continue antiepileptic medication, although the patient could be on less medication than before.

Five Ways to Protect Yourself and Your Loved Ones After a Traumatic Brain Injury (TBI)

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Welcome home!  You are an American Hero!  Your arrival may not have been celebrated by a ticker-tape parade, but your family and friends are showering you with love.  Prayers for your safe return have been answered.
        
While deployed, however, you may have sustained the "signat
ure injury" of Operations Enduring Freedom, Iraqi Freedom, and New Dawn: Traumatic Brain Injury (TBI).  If you sustained a TBI, you are now a candidate for Post Traumatic Epilepsy (PTE), even if your TBI was classified as a Mild Traumatic Brain Injury (mTBI).  The greater the severity of the TBI, the greater the probability of developing PTE.  Currently there is nothing that indicates whether you will or will not develop PTE.  There is also no way of knowing when you will have your first seizure if you do develop this potentially life-threatening medical condition.  So, how do you protect yourself and your family?

1.  Get screened for TBI. 

Even if you were not struck in the head by anything, you may have suffered an mTBI (concussion).  The energy blast alone from an Improvised Explosive Device (IED) can be enough to cause a TBI.  At a minimum, use an online TBI screening tool to help you make an informed decision about whether or not you want to get a formal screening.
 

2.  Know the symptoms of TBI

Also make sure your family knows and understands the symptoms and are able to recognize them.  Review these symptoms with your family often.  Remember, sometimes your family is better able to recognize when something is wrong than you are.
       

3.  Know how to administer First Aid for seizures…

Make sure your family is well-trained in seizure First Aid.  Many doctors are now asking that in addition to applying First Aid for seizures, someone should video the seizure.  A doctor will be able to understand more about a seizure from a video than from someone's description of the seizure.
       

4.  Know what resources are available to you.

MAKE THE CONNECTION is a good place to start your research about resources available to veterans.
       

5.  Develop an emergency plan for your family. 

Your emergency plan should begin with your immediate registration with the Department of Veteran Affairs.  If you develop PTE, life will change for you and your family.  You may not be able to return to work for an extended period of time.  Create and fund an emergency financial account.  America's financial guru, Dave Ramsey, suggests a financial emergency fund of 3 to 6 months of expenses.  Your emergency plan should also include child care, transportation, and a home health care-giver.  Your emergency plan should also include contacting and getting to know the Epilepsy Foundation that serves your area.

Remember...the more you know, the better prepared you will be. 

The more prepared you are, the greater the likelihood that you and your family will remain safe.

Dr. Sally Mathias

Dr. Sally Mathias completed her neurology residency at University of Kentucky followed by a fellowship in epilepsy at Vanderbilt University. She is double board certified, in neurology and epilepsy. 

Dr Mathias has a dual appointment as a neurologist and epilepsy specialist, at University of Kentucky Hospital and also the Veterans Health Administration in Lexington, KY. She has won several awards for teaching, mentorship and research in the last 5 years. She is also a member of several committees within UK, VA and on a national level.

She is the only board certified epilepsy specialist employed by the VA in the state of KY. 

Since joining the VA in 2016, she has started a specialized clinic for epilepsy where she sees veterans from all over Kentucky and nearby states (TN, IN, WV) for difficult to control epilepsy. Some veterans have successfully undergone epilepsy surgery and some of them are in the process of getting epilepsy surgery done. 

Dr Mathias has been instrumental in making the Lexington VA one of the consortium sites for the National VA Epilepsy Centers of Excellence. 

Dr Mathias has always had a deep inclination to care for the ones who have served and she is striving her very best to provide excellent state of the art epilepsy care for the veterans at the Lexington VA. 

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