Perioperative clinical and radiological predictors of late post-traumatic seizures in surgically treated patients with depressed skull fractures: A prospective observational study.

Abstract

Objective: This study aimed to identify perioperative clinical and radiological factors that predict the risk of developing late posttraumatic seizures (PTS) within 24 months of injury among surgically managed traumatic brain injury (TBI) patients with depressed skull fracture (DSF).

Methods: A prospective cohort study was conducted at Mulago Hospital, Uganda, involving mild-to-moderate TBI patients with DSF, followed up perioperatively and at outpatient clinics, and additionally via phone interviews for up to 24 months. The study monitored the incidence and recurrence of late PTS.

Results: The cohort included 171 patients with DSF, with a median age of 24 years (interquartile range = 15-31), 89.5% of whom were male, and 49.73% were assault victims. Approximately 73.1% had mild TBI, and 25% had a history of immediate or early PTS. The frontal bone was most commonly involved (46.2%). Over 24 months, nine patients (5.3%) experienced their first late PTS within 6 months, and a total of 20 reported late PTS by the end of follow-up (277.17 person-years, with 37 lost to follow-up). Incidence rate of late PTS was higher among those with a history of immediate and early PTS (.1319 vs. .0527, p = .0449). Multivariate analysis identified the absence of basal cisterns, midline shift (MLS) ≥ 5 mm, and dural tear as significant predictors of late PTS, with increased risks of sevenfold, fourfold, and >2.5-fold, respectively. Furthermore, abnormal basal cisterns were associated with a higher risk of late PTS recurrence.

Significance: A history of immediate or early PTS and abnormal radiological findings such as absent basal cisterns, MLS ≥ 5 mm, and dural tear are strong predictors of late PTS in DSF patients. The risk of developing late PTS gradually increases over time. We recommend aggressive management of increased intracranial pressure during the acute phase of TBI and systematic antiseizure prophylaxis to potentially mitigate the risk of late PTS. We also emphasize the importance of implementing long-term management and surveillance strategies for high-risk patients.