Neurologic Problems in the Athlete

Overview: Seizures involve both cerebral hemispheres, are of abrupt onset, and involve alteration in consciousness.

Tonic-clonic (grand mal): Occurs at all ages; may have a prodromal phase lasting hours to days. Typically starts with a tonic phase (rigid extension) lasting up to 20 seconds, followed by a clonic phase (synchronous muscle jerking) lasting 1–2 minutes; most last for <1 minute. Characteristics include loss of consciousness, convulsions, muscle rigidity, and urinary but not fecal incontinence; may progress to generalized status epilepticus; a postictal phase (confusion, headache, and fatigue) is common. May be followed by focal weakness or paralysis, including vision and speech function, reflecting postictal depression of the epileptogenic cortical area; this phenomenon, known as Todd paralysis , is reversible and usually resolves within 48 hours.

Absence (petit mal): Occurs generally in children; no prodromal or postictal phase reported.

• Typical: Onset is acute, as is recovery, with seizure activity lasting <10 seconds.

• Atypical: Lasts for >10 seconds, with more gradual onset and recovery; sudden loss of awareness with associated staring, rhythmic blinking, and possibly clonic jerks.

Generalized status epilepticus: Defined as a continuous seizure activity lasting 30 minutes or as two or more discrete seizures between which consciousness is not fully regained. Seizures lasting >5 minutes have a high likelihood of progressing to status epilepticus and should be treated aggressively. This is a medical emergency. Activate emergency medical services (EMS). Ensure adequate airway, breathing, and circulation. Attempt to obtain intravenous (IV) access and to prevent aspiration. Benzodiazepines are the drugs of choice for initial treatment because they are fast acting and effective. Lorazepam at a dose of 0.1 mg/kg IV over 2 minutes is considered first-line treatment. Consider metabolic etiologies. Complications include dysrhythmias, metabolic abnormalities, hyperthermia, pulmonary edema, rhabdomyolysis, and pulmonary aspiration.

Overview: Originate in a localized region of the brain and cause symptoms specific to the part of the cortex wherein they originate; partial seizures may become secondarily generalized.

Description: Provoked seizures after traumatic brain injury (TBI); classified by timing of the seizure activity

Immediate (concussive convulsions): Occurs within the first 24 hours after TBI; about one-half of seizures occur during the first 24 hours and one-quarter during the first hour; controversial classification, as they are not felt to represent a true seizure, but rather a fairly benign phenomenon that occurs immediately after a concussion; usually do not require anticonvulsant therapy

Early: Occurs within 1 week of TBI; risk factors include young age, severity of injury, alcoholism, and intracerebral or subdural hematoma. Incidence is approximately 6%–10% but higher in patients with marked head injury. Seizure activity is usually tonic-clonic within the first 24 hours, progressing to more focal symptoms thereafter. A computed tomography (CT) scan of the head is indicated, considering the higher incidence of intracranial bleeding; not felt to represent epilepsy but often treated with prophylactic antiepileptic medication to minimize the risk of status epilepticus and secondary injury; treatment with antiepileptic medications does not affect the risk of posttraumatic epilepsy.

Late: Occurs over 1 week after TBI, with most occurring before 2 years after injury.

• Risk factors: Early posttraumatic seizures, severity of injury, age >65 years, alcoholism, brain contusion, and intracerebral or subdural hematoma. Overall incidence is approximately 2% but is strongly correlated with severity of TBI. Seizures are also associated with underlying brain pathology. They may recur in up to 70% of cases and often require long-term anticonvulsant medication.