Do charts for intracranial hemorrhage require Keppra (levetiracetam) prophylaxis?

From the Guidelines

Prophylactic Keppra (levetiracetam) is not recommended for routine use in patients with intracranial hemorrhage, as recent studies have not consistently identified harm or benefit from its use with respect to global functional outcomes. When considering the management of patients with spontaneous intracerebral hemorrhage, the 2022 guideline from the American Heart Association/American Stroke Association 1 provides valuable insights. The use of alternative prophylactic antiseizure drugs such as levetiracetam may have become more common, but recent studies have not shown a clear benefit in preventing seizures or improving functional outcomes in patients with ICH. Some key points to consider include:

• Earlier studies suggested that prophylactic anti-seizure drugs such as phenytoin were associated with worse outcomes in patients with ICH 1.
• A meta-analysis found that seizure prophylaxis in patients with ICH was not associated with preventing either early or long-term seizures 1.
• Another meta-analysis reported that neither levetiracetam nor phenytoin prophylaxis was associated with worse functional outcomes at the longest follow-up or 90 days 1. In clinical practice, the decision to use prophylactic antiseizure drugs such as levetiracetam should be made on a case-by-case basis, taking into account the individual patient's risk factors and potential benefits and harms. However, based on the current evidence, routine use of prophylactic Keppra (levetiracetam) is not recommended for patients with intracranial hemorrhage.

From the Research

Seizure Prophylaxis in Intracranial Hemorrhage

• The use of levetiracetam for seizure prophylaxis in patients with intracranial hemorrhage is a common practice, but its efficacy and optimal dosing remain unclear 2, 3, 4, 5, 6.
• Studies have shown that levetiracetam may be effective in reducing the incidence of seizures in patients with traumatic brain injury and intracranial hemorrhage, but the evidence is not conclusive 2, 3, 4.
• A meta-analysis found that levetiracetam and phenytoin have equal efficacy in preventing seizures after brain injury, but the quality of the evidence is limited by the small number of randomized controlled trials 5.
• Another systematic review and meta-analysis found that levetiracetam may be preferred for seizure prophylaxis after supratentorial neurosurgery, but the evidence is not sufficient to support its use in traumatic brain injury, subarachnoid hemorrhage, or intracerebral hemorrhage 6.

Optimal Dosing of Levetiracetam

• The optimal dosing of levetiracetam for seizure prophylaxis is not well established, but studies suggest that higher doses (750-1000 mg twice daily) may be more effective than lower doses (500 mg twice daily) 3, 4.
• A retrospective cohort study found that patients receiving a total daily dose of levetiracetam greater than 1000 mg had a lower incidence of seizures than those receiving a dose of 1000 mg or less 4.
• However, the evidence is not sufficient to determine the optimal dosing regimen, and further studies are needed to establish the most effective and safe dose of levetiracetam for seizure prophylaxis 3, 4, 6.

Adverse Events

• Levetiracetam is generally well-tolerated, but adverse events such as anemia, leukopenia, and thrombocytopenia have been reported 4, 6.
• The incidence of adverse events is generally lower with levetiracetam than with other antiseizure medications, but the evidence is limited by the small number of studies and the variability in dosing regimens 6.