Which types of intracranial hemorrhages require prophylactic Levetiracetam (Keppra)?

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Dainyal Siddiqui, MD

Internal Medicine

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Manuel Jimenez, MD

Cardiology

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Franz Pierre-Louis, MD

Infectious Disease

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Last updated: February 28, 2025 • View editorial policy

From the Guidelines

Patients with a history of seizures or CNS disease, particularly those undergoing CAR T cell therapy, should receive prophylactic Levetiracetam (Keppra) to prevent seizures and potentially reduce the risk of intracranial hemorrhage complications. According to the most recent and highest quality study 1, Levetiracetam is recommended for patients with CNS disease or a history of seizures, with a dosing regimen of 10 mg/kg, up to a maximum of 500 mg per dose, every 12 hours for 30 days following infusion. This is because Levetiracetam has a minimal risk of adverse drug interactions and is generally well-tolerated, making it a suitable choice for prophylaxis in this patient population.

The use of Levetiracetam for prophylaxis is supported by its mechanism of action, which involves binding to synaptic vesicle protein SV2A, inhibiting neurotransmitter release, and reducing neuronal excitability. This can help prevent early post-traumatic seizures, which can worsen secondary brain injury and lead to poorer outcomes. Additionally, Levetiracetam has fewer drug interactions and less monitoring requirements compared to older anti-seizure medications like phenytoin, making it a more favorable choice for patients with complex medical conditions.

Some key points to consider when using Levetiracetam for prophylaxis include:

  • Dose adjustments may be necessary in patients with renal dysfunction
  • Patients should be monitored for signs and symptoms of cerebral edema and status epilepticus
  • Neurology consultation should be considered if the patient develops grade 1 CRES or for specialized screening for papilloedema
  • Patients should have a caregiver available who can observe for signs of CRES and seek prompt intervention for at least 4 weeks after CAR T cell infusion.

It is essential to note that the evidence from 2 does not provide specific guidance on the use of Levetiracetam for prophylaxis in patients with intracranial hemorrhage, but the study from 1 provides more relevant and up-to-date information on this topic. Therefore, the recommendation is based on the most recent and highest quality study available.

From the Research

Types of Intracranial Hemorrhages Requiring Prophylactic Levetiracetam (Keppra)

  • Intracerebral hemorrhage (ICH): There is no clear evidence to support the use of prophylactic Levetiracetam in patients with ICH 3, 4.
  • Traumatic brain injury (TBI): The use of prophylactic Levetiracetam in patients with TBI is not supported by current evidence 5, 4.
  • Aneurysmal subarachnoid hemorrhage (aSAH): Short-term prophylaxis with Levetiracetam may be beneficial in patients with aSAH, particularly those with a poor clinical grade or thick cisternal blood 3.
  • Supratentorial neurosurgery: Levetiracetam may be preferred for seizure prophylaxis in patients undergoing supratentorial neurosurgery 4.

High-Risk Patients

  • Patients with ICH in close proximity to the cortical surface 3.
  • Patients with aSAH and a poor clinical grade (poor neurologic examination and/or thick cisternal blood) 3.
  • Patients with seizures at the onset of their hemorrhage 3.

Note

The current evidence does not strongly support the use of prophylactic Levetiracetam in most types of intracranial hemorrhages, except possibly in patients undergoing supratentorial neurosurgery or those with aSAH and high-risk features 5, 3, 4.

References

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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