From the Guidelines
Levetiracetam (Keppra) prophylaxis is not recommended for primary prevention of post-traumatic seizures in traumatic brain injury (TBI) patients, except in cases with specific risk factors such as chronic subdural hematoma or past history of epilepsy. The decision to use levetiracetam prophylaxis should be based on individual patient risk factors, as the overall evidence does not support its routine use in TBI patients 1. Some of the risk factors that may warrant consideration of levetiracetam prophylaxis include:
- Chronic subdural hematoma
- Past history of epilepsy
- Brain contusion
- Acute subdural hematoma
- Skull fracture
- Initial loss of consciousness or amnesia for more than 24 hours
- Age over 65 years The typical dosing regimen for levetiracetam is 500-1000 mg twice daily, initiated within 24 hours of injury and continued for 7 days in most cases, though some centers extend treatment to 14 days 1. Levetiracetam is preferred over older anticonvulsants like phenytoin due to its higher degree of tolerance and more favorable side effect profile 1. It's essential to note that the evidence for preventing late seizures is less robust, so treatment beyond 7-14 days is generally not recommended unless the patient has experienced seizures 1. In clinical practice, the use of levetiracetam prophylaxis should be individualized, taking into account the patient's specific risk factors and medical history, as well as the potential benefits and risks of treatment 1.
From the Research
Indications for Levetiracetam Prophylaxis in Traumatic Brain Injury (TBI)
- The use of levetiracetam for seizure prophylaxis in TBI patients is a topic of ongoing debate, with some studies suggesting its effectiveness in preventing early posttraumatic seizures 2, 3.
- However, other studies have raised questions about the efficacy of levetiracetam in preventing seizures, particularly in patients with mild-to-moderate TBI 4, 5.
- The current evidence suggests that levetiracetam may be effective in preventing early posttraumatic seizures in patients with severe TBI, but its use in patients with mild-to-moderate TBI may not be warranted 2, 5.
- The optimal dosing strategy for levetiracetam in TBI patients is also unclear, with some studies suggesting that lower doses may be effective in preventing seizures 6, 3.
Patient Selection for Levetiracetam Prophylaxis
- Patients with severe TBI (Glasgow Coma Scale score ≤ 8) may benefit from levetiracetam prophylaxis, as they are at higher risk of developing early posttraumatic seizures 2, 4.
- Patients with mild-to-moderate TBI (Glasgow Coma Scale score > 8) may not require levetiracetam prophylaxis, as the risk of seizures is lower in this population 5.
- Patients with a history of seizures or other risk factors for seizures may require individualized consideration for levetiracetam prophylaxis 5.
Dosing Strategies for Levetiracetam Prophylaxis
- The optimal dose of levetiracetam for seizure prophylaxis in TBI patients is unclear, with studies suggesting a range of doses from 500 mg every 12 hours to 2000 mg per day 6, 3.
- Lower doses of levetiracetam (500 mg every 12 hours) may be effective in preventing seizures, but further studies are needed to confirm this finding 3.
- Higher doses of levetiracetam (≥ 2000 mg per day) may not provide additional benefit in preventing seizures, and may be associated with increased adverse effects 6.