What anti-seizure medication is recommended for a patient with ongoing seizures after suffering a Subdural Hematoma (SDH) and subsequent cerebral infarction?

From the Guidelines

For a patient with ongoing seizures after subdural hematoma (SDH) and infarction, levetiracetam is the recommended first-line antiseizure medication. This recommendation is based on recent studies that suggest levetiracetam may have a trend toward better outcomes compared to other antiseizure medications, such as phenytoin, in patients with intracerebral hemorrhage 1. The use of levetiracetam is preferred due to its favorable pharmacokinetic profile, minimal drug interactions, and lack of requirement for serum level monitoring.

Some key points to consider when using levetiracetam in this context include:

• The typical starting dose is 500-1000 mg IV twice daily, with the option to transition to oral therapy when possible at the same dosage 1.
• In acute settings, loading doses of 20-60 mg/kg may be used to rapidly achieve therapeutic levels.
• Levetiracetam has both IV and oral formulations, making it a convenient option for patients with varying levels of consciousness or ability to take oral medications.
• Alternative options, such as lacosamide or valproate, may be considered in certain situations, but levetiracetam is generally the preferred first-line agent due to its safety and efficacy profile 1.

It is essential to continue treatment for at least 7 days after the acute injury, with consideration for longer therapy (3-6 months) depending on seizure recurrence, EEG findings, and the extent of brain injury 1. A neurology consultation is recommended for ongoing management and potential tapering of medication to ensure optimal patient outcomes.

From the FDA Drug Label

The therapeutic range is commonly considered to be 50 to 100 μg/mL of total valproate, although some patients may be controlled with lower or higher plasma concentrations The efficacy of divalproex sodium in reducing the incidence of complex partial seizures (CPS) that occur in isolation or in association with other seizure types was established in two controlled trials

The patient should be given valproate (PO), as it has been shown to be effective in reducing the incidence of complex partial seizures.

• The therapeutic range of valproate is 50 to 100 μg/mL, although some patients may be controlled with lower or higher plasma concentrations.
• It is essential to monitor plasma concentrations and adjust the dose accordingly to achieve optimal seizure control.
• The patient should be closely monitored for adverse effects, such as thrombocytopenia, somnolence, and suicidal thoughts or behavior 2 2.

From the Research

Seizure Management in Patients with Subdural Hematoma and Infarction

• The choice of anti-seizure medication for patients with ongoing seizures after subdural hematoma (SDH) and infarction is crucial, with levetiracetam and phenytoin being commonly used options 3, 4.
• A systematic review and meta-analysis found that levetiracetam may be preferred for seizure prophylaxis in patients with supratentorial neurosurgery, but its efficacy in preventing seizures in patients with SDH and infarction is unclear 5.
• A retrospective cohort study comparing levetiracetam and phenytoin for seizure prophylaxis in patients with acute or subacute SDH found no significant difference in seizure risk, but levetiracetam was associated with a lower risk of adverse events 3.
• Another study found that in patients with isolated SDH and preserved consciousness, in-hospital seizures were rare regardless of seizure medication use, with levetiracetam being the most commonly used medication 6.
• A systematic review of epileptic seizures in adults with SDH found that phenytoin and levetiracetam had similar efficacy in preventing post-traumatic seizures, but levetiracetam was associated with significantly lower adverse effects 4.
• The medical management of SDH focuses on maintaining adequate cerebral perfusion, preventing seizures, and managing intracranial hypertension, with anti-seizure medications being a crucial part of this management 7.

Key Considerations

• The choice of anti-seizure medication should be individualized based on the patient's specific needs and medical history.
• Levetiracetam may be a preferred option for patients with SDH and infarction due to its lower risk of adverse events, but its efficacy in preventing seizures is unclear.
• Further studies are needed to determine the optimal anti-seizure medication for patients with SDH and infarction, with consideration of factors such as seizure risk, adverse event profile, and patient-specific characteristics 5, 3, 4.