Sunday, December 6, 2009

Soldiers and their Seizures

Brenda Patoine has written an interesting and ominous piece about the coming tidal wave of seizure disorders among veterans returning from Iraq. Traumatic brain injury (TBI) has always been associated with a high incidence of epilepsy, which may show up months, and often years, after the initial injury. Many soldiers returning from Iraq and Afghanistan have begun to have seizures and many many more will begin to, even as they settle unsuspectingly back in to life at home. The article, on the Epilepsy Foundation's website, cites 1985 study of vets who’d suffered traumatic brain injury in Vietnam found that 50 percent developed seizure disorders within a few years of returning home.
Patoine writes:
"No one knows how many of those troops with brain injuries will eventually develop epilepsy. But with an estimated 1.4 million troops who have served or are currently serving in Iraq, even the most conservative statistics portend a looming crisis of post-TBI neurologic problems.…”

Patoine goes on to quote Marc Dichter at the University of Pennsylvania who pleas for  preventive action for these high-risk soldiers. “Basically, we’ve been waiting for epilepsy to happen and then seeing if we can treat it… Why aren’t we paying attention to the development of epilepsy, as we do for every other medical disease?” he asks.

Pantione then outlines a few trials that look at how well various anti-seizure meds work as prophylactics for seizures if they are administered soon after the initial injury. That’s a worthwhile approach, sure, but is administering anti-seizure meds as a prevention really the whole deal? I don't know, but either the article failed to describe other avenues of research, or they aren’t happening. Have VA docs looked for patterns in the EEGs of soldiers with TBI but still no seizures, for example, to see which ones develop epilepsy and which ones don’t? Some people are more likely to develop seizures after brain injury, while others have more resilience due to, say, greater adaptive plasticity, or some other mechanism. What about the increase of gabapentin after injury and its influence on the growth of new synaptic connections; might that acceleration of healing growth also make brains more susceptible to seize? Or maybe (probably) those soldiers who become epileptic would have been more likely to begin seizing anyway; the injury just pushes them over the line. If that's the case, what made them so? Is there a genetic link? How about the specific kind and location and intensity of the brain injury? Are those details being tracked as determinants of seizure onset? And finally, how many of these seizures are psychogenic non-epileptic seizures (PNES)? Do VA doctors really know?

This would be a great time to study these things, both for the soon-to-be epileptic soldiers with head injuries and for the millions of non combatants who are going to begin having seizures in the years to come but don't know it. If we can identify their propensity, and mitigate it, before the onset of full-blown seizures, that would be a huge advance.

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