Seizure related injuries among outpatients in two tertiary hospitals in South East Nigeria

Introduction: Epilepsy is the most prevalent and serious neurological disorder occurring in the community. The large treatment gap in developing countries places a lot of patients at risk of severe seizure-related injuries and death. Accurate data on the prevalence and pattern of epilepsy-related injuries does not exist in south-east Nigeria. Aims: To determine the prevalence and pattern of seizure-related injuries in patients with epilepsy attending the neurology clinics. Setting: Neurology clinic of 2 urban referral centers in south-east Nigeria. Design: Questionnaire-based cross-sectional study. Materials and Methods: All patients above 18 years with active epilepsy were included and were interviewed. Injuries included in the study were those directly related to seizures or of unknown cause but suspected to be due to seizures. Injuries that patients believed were of a non-seizure related etiology were excluded. Data was analyzed using SPSS v 17. Results: 86(98.9%) patients reported a history of injury related to seizures; 28 (32.1%) patients had moderate to severe injuries while 59(67.8%) patients had only minor injuries. Loss of teeth and injury to the head were the commonest forms of injury (10.3 and 9.1% respectively). There was a slightly higher rate of serious injuries in women and in patients above 45 years. Conclusion: Severe body injuries are common in outpatients with active epilepsy. Loss of tooth and head injuries were the most common forms of severe injuries encountered. Adequate treatment and precautions are needed to prevent seizure-related injury from impacting negatively on the quality of their lives.

Keywords: Epilepsy, injuries, Nigeria, prevalence pattern

Epilepsy is the most prevalent and serious neurological disorder ^[1],[2] occurring in more than 50 million people worldwide. ^[3] The large treatment gap in developing countries ^[3] places a lot of patients at risk of severe seizure-related injuries and death. The overall risk of fractures is nearly twice as high among patients with epilepsy as compared with the general population. ^[4] Retrospective, population-based studies have also suggested increased rates of more serious injuries. ^[5],[6] Higher seizure frequency, lack of a prolonged seizure-free interval, comorbid attention deficit disorder, or cognitive handicap also increase the risk of injury. ^{[5],[6],[7],[8],[9]} Since seizure frequency is related to adequacy of care it is easy to understand why seizure-related trauma and deaths may be higher in Sub Saharan Africa. Accurate data on the prevalence and pattern of epilepsy-related injuries is essential to place epilepsy correctly within the rank of public health disease context.

Between January to September 2010, a total of 87 consecutive consenting patients presenting to neurology outpatient clinic of the University of Nigeria teaching Hospital and the Federal neuropsychiatric Hospital Enugu were recruited and interviewed All patients above 18 years with active epilepsy were included and underwent a one-to-one interview inquiring about their history of injuries, and whether these were known to be directly related to their seizures. The questions were structured and administered in English or in vernacular. The number of seizures in the last 4 years, nature, severity, circumstances leading to, consequences of the injuries, and the mode of treatment received were determined. Current drugs used by the patients were also recorded. Injuries were defined as any accidental occurrence leading to dysfunction or pain in any part of the body. Injuries included in the study were those directly related to seizures or of unknown cause but suspected to be due to seizures. Injuries that patients believed were of a non-seizure related etiologies were excluded. Injury severity was classified as mild, moderate, or severe using a modified classification system based on a prior scale. ^[10] If the patient was unable to give details of the injury, the care giver that witnessed the injury was questioned as well. Data was analyzed using SPSS v 17.

The mean age of the patients was 33.33 years (males-32.3, females-35.0.P=0.423) (range 14-85 years). Males were 54(62.1%), and females were 33(37.9%). The male female ratio was 1.6:1. Seizure duration was 4 months to 47 years with a mean of 10.8(±10.2) years.

The mean number of seizures in the last 1 year was 2.9 (±3.2). 57(65.5%) patients reported less than 5 seizures. Of this number, 40 (46%) patients had only 1 seizure. 11(12.6%) patients had 5 to 9 seizures within, this period and 5(5.7%) patients also had 10 or more (10-18) seizures within the same period. 14(16.1%) patients could not recollect the number of seizures they had within the last 1 year. 86(98.9%) patients reported a history of injury related to seizures. 28(32.1%) patients in addition to minor injuries also sustained moderate to severe injury. The pattern of injury is shown in [Table 1] and [Table 2]. 1 case of physical assault was reported.

One person had sustained multiple severe injuries in the past. Women (37.9%) of the population accounted for 47.1% of all severe injuries. The mode of treatment was mainly self-medication. Only those with dislocation and fracture sought medical attention.

Even though patients with epilepsy can live relatively unrestricted lives, the risk of injury due to a seizure is a source of great concern for both clinicians and patients. ^[11],[12] In this study, 98.9% of the epilepsy patients had sustained some form of injury. Though most of these were minor injuries (67.9 % were mainly bruises), 32.1% had moderate to severe injury. The mean annual frequency of seizures was 2.9. This might be an underestimate considering that 19.1% could not quantify the number of seizures they had in the past 1 year. Following the injuries, a small percentage of patients sought medical attention because of injury (6.9%).

Previous studies have shown that seizures with falls do have a 20% chance of injury ^[13] and seizure-related injuries occur in 30% to 35% of patients per year, ^[7],[14] but most injuries (44-80%) are minor and are healed with minimal or no intervention ^{[7],[14],[15]} as also observed in this study. In a population-based study in Rochester, MN, 16% of epilepsy patients had at least 1 seizure-related injury, ^[8] much less than 98.9% in the index study; however, this present study recruited only those with active epilepsy.

The risk of fracture in epilepsy is elevated. This results directly from seizure-induced injury or predisposed by drug-induced reduction in bone mineral density. Seizures resulting in falls increase the risk of concussion and other injuries. A small percentage of the population studied has fractures (2.3%) and dislocations (4.6%). In one study, about 1% of seizures with a fall are associated with fractures, compared to about 0.25% following all seizures. ^[16]

Dental injuries were the most common form of severe injury noted in this study. Together with severe head injuries, which are likely to be associated with loss of tooth, they constitute 60.7% of severe injuries and 19.3% of all injuries. In a previous study, ^[13] head injury accounted for 14% of all injury events less than 19.3% in this study. Head injuries have been reported to occur in 3% of all seizures ^[17] and have a cumulative risk of occurring at a rate of 2% per year. ^[6] Repeated head injuries may be a cause of cognitive impairment seen in epilepsy as undocumented head trauma may affect cognitive functioning. ^[18],[19] Dental injuries and the subsequent need for dental prosthesis even when affordable will add to an already high economic burden of epilepsy. Chronic disfiguring traumas such as facial scars, loss of tooth will worsen the burden to stigma in epilepsy. ^[20]

Fall from a height was reported in 4.6% of the patients. Many factors may contribute to such occurrences for example, engaging in farming activities and unsupervised plays in adolescents. These falls may have dire consequences if they occur from a great height or near a river.

No patient reported any case of burns since the onset of epilepsy despite the fact that many may be active at home and are likely to be involved in cooking. Kinton and Duncan ^[21] reported that hot water and rarely cooking were the cause of most burns. One reason for this may be cold weather and the need for hot water for bathing in temperate countries and not in hot tropical climates like Nigeria. Spitz ^[9] reported a linear relationship between the number of seizures and associated burns with cooking on a stove as the most influential factor. The absence of burns cases in this study may be due to cultural beliefs concerning epilepsy and fire. Increasing awareness of seizure-related injuries among the populace and patients maybe another factor limiting the use of open fires by patients.

One case of assault in a patient with complex partial seizure was reported. In developing countries, atypical forms of seizures may not be easily recognized by health care workers and this may delay treatment. Burns and assault occurring in complex partial seizures occur frequently and remain unexplained and not presumed to be seizure-related. ^[9],[22] Studies indicate that more than 40% of complex partial seizures confirmed by video-EEG monitoring, including those that secondarily generalize, are not identified as seizures by the patient. ^[14],[15]

The pattern of injury found in this study was different from to those of prior studies. ^{[6],[7],[15],[23]} In fact, loss of tooth and fractures/dislocations were seen in more than 50% of those with moderate/severe injuries. Contrary to other studies, ^[9],[13] the pattern of injuries appeared similar in both sexes. This similarity in the pattern of injuries between men and women and the differences between the age groups is not readily explained because some of the injuries might have occurred some years earlier

Several limitations of the study should be recognized. The data presented are based on a relatively small and highly selected sample from 2 urban clinics, which may not be generalizable to other epilepsy populations. Our patients consisted of those with active epilepsy, and, therefore, the data may be representative of one of the less favorable outcome groups. Population-based studies are necessary to address the burden of seizure-related injuries in epilepsy patients.

Injuries are common among patients with epilepsy. Severe injuries occur in more than one third of the cases. Head and dental injuries are the most common forms of severe injuries encountered. Burns and near drowning were not found among the patients studied. Patients with epilepsy can lead normal lives, but precautions are needed to prevent seizure-related injury from impacting negatively on the quality of their lives.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.102047

[Table 1], [Table 2]