Post-traumatic epilepsy as a consequence of gunshot penetrating head injury with intracranial metallic foreign body: epidemiology, prevention, and treatment algorithms

BACKGROUND: The growing number of armed conflicts worldwide is leading to an increase in patients with combat-related traumatic brain injury, including those with intracranial metallic foreign bodies. Acute symptomatic post-traumatic epileptic seizures constitute a cause of secondary brain injury, whereas post-traumatic epilepsy may become the only disabling and quality-of-life-limiting consequence of head trauma, requiring prolonged antiseizure therapy.

AIM: This work aimed to investigate epidemiological features, diagnostic characteristics of epileptic seizures, and post-traumatic epilepsy in military personnel with intracranial metallic foreign bodies, and to evaluate algorithms for preventive antiseizure medication and treatment of post-traumatic epilepsy.

METHODS: A prospective study included 93 military personnel who sustained a gunshot penetrating head injury with an intracranial metallic foreign body. Patients were divided into two groups: group 1 (n = 63) with intracranial metallic foreign body retained; group 2 (n = 30) with intracranial metallic foreign body surgically removed within 4 months post-injury. To assess different approaches to preventive antiseizure therapy, both groups were subdivided into two subgroups: patients receiving prophylactic antiseizure medications (1a and 2a); patients without prophylactic antiseizure treatment (1b and 2b).

RESULTS: Post-traumatic epilepsy was diagnosed in 18 of 93 patients (19.4%). In group 1, a total of 13 patients (20.6%) developed epilepsy: 8 of 27 (29.6%) in subgroup 1a and 5 of 36 (13.9%) in subgroup 1b. In group 2, epilepsy occurred in 5 patients (16.7%): 4 of 16 (25%) in subgroup 2a and 1 of 14 (7.1%) in subgroup 2b. Among group 1 patients with post-traumatic epilepsy (n = 13), epileptiform activity on electroencephalogram was detected in 7 patients (53.8%), and paroxysmal slow-wave activity in 3 patients (23.1%). In subgroups, epileptiform activity was detected in 6 patients (22.2%) and paroxysmal slow-wave activity in 5 patients (18.5%) in 1a; and in 5 patients (13.9%) and 4 patients (11.1%) in 1b, respectively. Among subgroup 2a patients, epileptiform activity or paroxysmal slow-wave activity were detected in 8 of 16 patients (50%), with 4 patients demonstrating either pattern. In subgroup 2b, 13 of 14 patients demonstrated no epileptiform or paroxysmal slow-wave activity on electroencephalogram.

CONCLUSION: An intracranial metallic foreign body is a significant risk factor for post-traumatic epilepsy. The use of antiseizure medications for prophylaxis of epileptic seizures in this group of military personnel is not recommended. Paroxysmal slow-wave activity on electroencephalogram serves as a predictor of post-traumatic epilepsy and may guide preventive and therapeutic decision-making algorithms.