Cranial Vault Fractures in Civilian Head Injury: Clinical and Radiologic Predictors of Seizures and the Fracture Seizure Index: A Prospective Single-Center Observational Cohort Study

Abstract

Study Objectives To determine the risk factors of posttraumatic seizures (PTS) among patients with civilian head injury and skull vault fractures.

Methods A 5-year prospective cohort study of patients with skull fractures presenting to our center from March 2013 to February 2017.

Results Of 637 patients with traumatic brain injury (TBI), 135 (21.2%) patients sustained calvarial fractures, 91 (72%) were from road traffic accidents (RTAs), and most were young adult males (M:F = 11.6, mean age = 29.1 ± 2.3 years, 95% CL). Linear fractures in 69 patients and depressed fractures in 50 (39.7%) were the common fracture types. Seventy-seven (61.1%) patients had cerebral contusions, 31 (24.6%) had extradural hematoma (EDH), and 21 (16.7%) patients had Glasgow coma scale (GCS) ≤ 8. Twenty-five (18.5%) patients suffered early PTS, and five had late PTS. Among nonfracture patients (n = 361), 31 (8.6%) had seizures. Seizures occurred more in the fracture subgroup (χ² = 10.1, p < 0.05, df = 1) and earlier (χ² = 5.9, p = 0.027, df = 1). Fractures and seizures followed a similar trend in occurrence. Among patients with vault fractures, severe head injury, contusions, and intracranial hematoma, the relative risk and odds for early seizures followed a trend predicted by a statistical index—the fracture seizure index (FSI). Late PTS did not show a statistical relationship with early PTS (χ² = 2.98, df = 1, p > 0.05).

Conclusion GCS score ≤8, depressed fracture and multifocal cerebral contusions are predictors of early PTS. Seizure risk associated with fractures and other lesions can be predicted by the FSI.

Keywords

posttraumatic seizures - skull fracture - fracture seizure index

• References

• 1 Graham DI. Closed head injury. In: Mason JK, Purdue BN. eds. The Pathology of Trauma. 3rd ed.. London, UK: Arnold; 2000: 191-201
• 2 Gurdjian ES, Webster JE, Lissner HR. The mechanism of skull fracture. Radiology 1950; 54 (03) 313-339
• 3 Dunning J, Batchelor J, Stratford-Smith P. et al. A meta-analysis of variables that predict significant intracranial injury in minor head trauma. Arch Dis Child 2004; 89 (07) 653-659
• 4 Muñoz-Sánchez MA, Murillo-Cabezas F, Cayuela-Domínguez A, Rincón-Ferrari MD, Amaya-Villar R, León-Carrión J. Skull fracture, with or without clinical signs, in mTBI is an independent risk marker for neurosurgically relevant intracranial lesion: a cohort study. Brain Inj 2009; 23 (01) 39-44
• 5 DiMaio VJ, DiMaio D. Trauma to the skull and brain: craniocerebral injuries. In: DiMaio VJ, DiMaio D. eds. Forensic Pathology. 2nd ed.. CRC; 2001: 147-185
• 6 Frey LC. Epidemiology of posttraumatic epilepsy: a critical review. Epilepsia 2003; 44 (Suppl (10) 11-17
• 7 Annegers JF, Coan SP. The risks of epilepsy after traumatic brain injury. Seizure 2000; 9 (07) 453-457
• 8 Jasper US, Opara MC, Pyiki EB, Akinrolie O. The epidemiology of hospital referred head injury in Northern Nigeria. JSRR 2014; 3 (15) 2055-2064
• 9 Tseng WC, Shih HM, Su YC, Chen HW, Hsiao KY, Chen IC. The association between skull bone fractures and outcomes in patients with severe traumatic brain injury. J Trauma 2011; 71 (06) 1611-1614 discussion 1614
• 10 Johnstone AJ, Zuberi SH, Scobie WG. Skull fractures in children: a population study. J Accid Emerg Med 1996; 13 (06) 386-389
• 11 Emejulu JKC, Isiguzo CM, Agbasoga CE, Ogbuagu CN. Traumatic brain injury in the accident and emergency department of a tertiary hospital in Nigeria. East Cent Afr J Surg 2010; 15: 28-38
• 12 Thapa A, Chandra SP, Sinha S, Sreenivas V, Sharma BS, Tripathi M. Post-traumatic seizures—a prospective study from a tertiary level trauma center in a developing country. Seizure 2010; 19 (04) 211-216
• 13 Yeh CC, Chen TL, Hu CJ, Chiu WT, Liao CC. Risk of epilepsy after traumatic brain injury: a retrospective population-based cohort study. J Neurol Neurosurg Psychiatry 2013; 84 (04) 441-445
• 14 Jennett B, Miller JD, Braakman R. Epilepsy after monmissile depressed skull fracture. J Neurosurg 1974; 41 (02) 208-216
• 15 Weiss GH, Feeney DM, Caveness WF. et al. Prognostic factors for the occurrence of posttraumatic epilepsy. Arch Neurol 1983; 40 (01) 7-10
• 16 Weiss GH, Salazar AM, Vance SC, Grafman JH, Jabbari B. Predicting posttraumatic epilepsy in penetrating head injury. Arch Neurol 1986; 43 (08) 771-773
• 17 Feeney DM, Walker AE. The prediction of posttraumatic epilepsy. A mathematical approach. Arch Neurol 1979; 36 (01) 8-12
• 18 Zanier ER, Lee SM, Vespa PM, Giza CC, Hovda DA. Increased hippocampal CA3 vulnerability to low-level kainic acid following lateral fluid percussion injury. J Neurotrauma 2003; 20 (05) 409-420
• 19 Kovesdi E, Kamnaksh A, Wingo D. et al. Acute minocycline treatment mitigates the symptoms of mild blast-induced traumatic brain injury. Front Neurol 2012; 3: 111
• 20 Jennet B. Epilepsy after non–missile head injuries. 2nd ed.. London, UK: William Heinemann; 1973: 175
• 21 Diaz-Arrastia R, Gong Y, Fair S. et al. Increased risk of late post-traumatic seizures associated with inheritance of APOE epsilon4 allele. Arch Neurol 2003; 60 (06) 818-822
• 22 Asikainen I, Kaste M, Sarna S. Early and late posttraumatic seizures in traumatic brain injury rehabilitation patients: brain injury factors causing late seizures and influence of seizures on long-term outcome. Epilepsia 1999; 40 (05) 584-589