Management and Return to Play Considerations in an Elite Hockey Player with Temporal Lobe Epilepsy

Temporal lobe epilepsy (TLE) is a common form of epilepsy that presents with complex partial seizures and in some cases with generalization to tonic-clonic activity that are often well controlled with antiepileptic medication in up to two thirds of patients. The remaining one third with “medically intractable” TLE may benefit from surgical temporal lobectomy, which offers considerably higher rates of seizure freedom than medication alone (1–3). A new diagnosis of TLE in athletes competing in contact sports can present a challenge for managing physicians who must weigh the risks and benefits of continued sports participation (4,5) and plan for potential future injuries including concussions. Here, we report the case of a 17-year-old male junior hockey player who presented with newly diagnosed TLE to illustrate the value of a multidisciplinary approach to medical and return-to-sports management in this unique athlete population. Case Report A previously healthy 17 year-old junior hockey player was asleep on the team bus when his teammates witnessed him have a 2- to 3-min generalized tonic-clonic seizure followed by a period of postictal fatigue. The patient was taken to a nearby emergency department where he underwent computerized tomography imaging of the brain that was interpreted as normal. The patient was seen by a general neurologist who completed a clinical history, physical examination, and arranged magnetic resonance imaging (MRI) of the brain and a sleep-deprived electroencephalography (EEG). The athlete's medical history was unremarkable for any previous seizure events, neonatal infections, substance use, or head injuries. Family history was positive for a great aunt who had epilepsy of unknown etiology. Upon further clinical history, the athlete reported several previous episodes where his teammates found him to acutely “zone out” during conversations consistent with focal seizures with impaired awareness. Complete neurological examination was normal. Initial brain MRI revealed an ill-defined nonenhancing lesion in the left mesial temporal lobe. Sleep-deprived EEG demonstrated occasional left frontotemporal spikes and slowing, suggestive for epileptiform activity. The athlete was managed with Lamotrigine 150 mg BID and temporary suspension of driving privileges. The injury occurred late in the hockey season so the patient was withheld from hockey for the remainder of the season while the diagnostic workup was completed, and seizure control was achieved. Before initiating antiepileptic medication, the athlete had a second witnessed generalized tonic-clonic seizure while sleeping. The athlete was referred by the team medical staff to a multidisciplinary pediatric epilepsy program and pediatric concussion program for a second opinion on medical management and guidance on return to competitive hockey. High-resolution brain MRI and magnetic resonance (MR) spectroscopy imaging was arranged demonstrating nonenhancing cortical thickening and T2 hyperintense tissue changes along the medial aspect of the left temporal lobe with involvement of the amygdala and hippocampal complex and enlargement of the left temporal horn of the lateral ventricle (Fig.). The MR spectroscopy demonstrated a reduction in N-acetyl-aspartate, a minimally elevated lactate peak, and no significant increases in markers of cell membrane turnover. These neuroimaging findings were suggestive for left mesial temporal sclerosis with associated cortical dysplasia or low grade glioma. Four months later, the patient remained seizure-free with stable repeat neuroimaging findings and expressed an interest to return to competitive junior hockey. The patient was currently playing in a junior hockey league that is one step below professional hockey in Canada where he would be at an elevated risk of sustaining repetitive head injuries and potentially a concussion. Given that 1) the patient's seizures were well controlled on a single antiepileptic medication, 2) he had never experienced an exercise or head injury-induced seizure, 3) he was participating in full on- and off-ice training workouts without seizure, and 4) he would be participating in a sport with no risk to bystanders under the supervision of the team medical staff—the athlete was medically cleared to return to competitive hockey. The athlete was informed of the potential risk of sustaining seizures during hockey activities that could result in additional physical injury. Because of the potential impact of the athlete's condition and medication on neuropsychological testing that could be used to assist in concussion management during the upcoming season, the athlete underwent computerized and pencil-and-paper neuropsychological testing by a neuropsychologist to establish a comprehensive baseline. The results of testing were found to be primarily within normal limits with the exception of impairments in verbal memory consistent with his temporal lobe pathology. In the 2 months since receiving formal medical clearance to return to full hockey-related activities, the patient has not experienced another seizure. The patient remains under the care of the multidisciplinary team and will undergo periodic clinical and MRI and MR spectroscopy surveillance to ensure seizure control is maintained and the neuroimaging findings remain stable.Figure: Coronal T2-weighted MRI of the brain demonstrates cortical thickening and hyperintense tissue changes along the medial aspect of the left temporal lobe with involvement of the amygdala and hippocampal complex (white arrow on the left) and enlargement of the left temporal horn of the left lateral ventricle (white arrow on the right). These features are suggestive for left-sided mesial temporal sclerosis and associated cortical dysplasia or low-grade glioma.Discussion Temporal lobe epilepsy is the most common epilepsy syndrome worldwide. Although its exact prevalence and incidence remains unclear, it is a frequent cause of epilepsy and medically refractory epilepsy in children and adolescents (3,6). Hippocampal sclerosis is found in 21% of pediatric TLE patients with 15% harboring dual pathologies, including cortical dysplasias or other gliotic lesions (2). Approximately two thirds of patients with newly diagnosed TLE will achieve seizure freedom or control with one or two antiepileptic medications with the remainder of medically refractory patients considered for surgery depending on the underlying pathological, electrophysiological, and neuropsychological features of the disease (1–3,6). Other epilepsy syndromes with onset in adolescence include juvenile absence or myoclonic epilepsies, progressive myoclonic epilepsy, reading and photosensitive epilepsies, and nonepileptic seizures (7). Historically, epilepsy patients were restricted from engaging in physical exercise and sports because of fear that such activities could precipitate a seizure through mechanisms, such as hyperventilation, alterations in antiepileptic drug metabolism, or exposure to head trauma (5). However, animal model and clinical research suggests that physical exercise is associated with reduced seizure activity and is unlikely to induce seizures even at high-intensity levels (8,9). Consequently, the International League Against Epilepsy (ILAE) recommends that return-to-sport decision making in patients with seizures and epilepsy should be made on an individualized basis and take into consideration factors, such as the number and type of seizures experienced, duration of seizure control, medication withdrawal, and the potential risk to the patient and bystanders associated with participation in different sports (4). At present, the ILAE suggests that patients with one or more symptomatic seizures may be considered for participation in supervised sports with a moderate risk of physical injury to the patient but not bystanders based on the neurologist’s discretion. One additional consideration that is unique to athletes participating in contact and collision sports is the impact of epilepsy on concussion management, which often relies on neuropsychological testing to aid in confirming clinical recovery. At present, there is insufficient evidence to support widespread baseline neurocognitive testing in youth athletes because of problems with the reliability of these tests in children and adolescents and a lack of research to support an added clinical value of this practice (10). However, baseline formal neuropsychological testing performed by a neuropsychologist should be considered in athletes with preexisting conditions that can affect cognitive functioning and in whom these tests may be used to inform return-to-sport clinical decision making. It is well documented that patients with epilepsy can exhibit deficits in cognitive functioning. As illustrated here, patients with TLE typically exhibit deficits in verbal memory, which are more common in patients with left-sided disease (11). Furthermore, antiepileptic medications also can contribute to neuropsychological impairments in patients with epilepsy (12). It is also important to note that antiepileptic medications also can result in side effects that mimic concussion-like symptoms, such as dizziness, fatigue, and nausea. In summary, athletes with TLE should be managed on an individualized basis by a multidisciplinary team of specialists with clinical expertise in epilepsy. This case suggests that baseline neuropsychological testing should be considered in athletes with epilepsy who are returning to sports with a risk of concussion.

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