What are the indications for Levetiracetam (Keppra) prophylaxis in Traumatic Brain Injury (TBI)?

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 haematoma or past history of epilepsy. The evidence from recent studies, including a 2018 review published in Anaesthesia 1, suggests that antiepileptic drugs, including levetiracetam, do not significantly reduce the incidence of early or delayed post-traumatic seizures.

Some key points to consider:

• The incidence of early clinical seizures (within 7 days after the brain injury) was 2.2%, and the incidence of delayed seizures (after 7 days) was 2.1% in severe TBI patients 1.
• Risk factors for delayed clinical seizures include brain contusion, acute subdural haematoma, skull fracture, initial loss of consciousness or amnesia for more than 24 hours, and age over 65 years 1.
• Eleven clinical trials studied primary prevention of post-traumatic seizures, but all had a low level of evidence, and no significant effect of antiepileptic drugs was found to prevent the occurrence of early or delayed post-traumatic seizures 1.
• Levetiracetam may be considered in cases with risk factors, due to its higher degree of tolerance compared to phenytoin 1.

In clinical practice, the decision to use levetiracetam prophylaxis should be based on individual patient risk factors and clinical judgment, rather than routine use for all TBI patients. If levetiracetam is used, the typical dosing regimen and duration of treatment should be determined on a case-by-case basis, taking into account the patient's specific risk factors and clinical condition.

From the Research

Indications for Levetiracetam (Keppra) Prophylaxis in Traumatic Brain Injury (TBI)

The indications for Levetiracetam (Keppra) prophylaxis in Traumatic Brain Injury (TBI) are not well-established, with varying results from different studies. Some key points to consider include:

• 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 post-traumatic seizures 2, 3.
• However, other studies have found that Levetiracetam may not be effective in preventing seizures in TBI patients, particularly in those with severe injuries 4, 5.
• A systematic review and meta-analysis found that the use of antiepileptic medications, including Levetiracetam, may have a protective effect against early seizures in TBI patients, but the evidence was modest and more studies are needed to confirm this finding 6.
• The choice of Levetiracetam as a prophylactic agent may be influenced by its favorable side effect profile and lack of significant pharmacokinetic interactions, compared to other antiepileptic medications such as phenytoin 3, 4.

Patient Selection for Levetiracetam Prophylaxis

The selection of patients for Levetiracetam prophylaxis in TBI is crucial, and may depend on various factors such as:

• Severity of injury: Patients with severe TBI may be at higher risk of developing post-traumatic seizures, and may benefit from prophylactic treatment with Levetiracetam or other antiepileptic medications 2, 4.
• Risk of seizures: Patients with a history of seizures or other risk factors for seizures may be more likely to benefit from prophylactic treatment with Levetiracetam 2, 5.
• Other medical conditions: Patients with other medical conditions, such as liver or kidney disease, may require careful consideration and monitoring when using Levetiracetam or other antiepileptic medications 3, 4.

Dosage and Administration of Levetiracetam

The dosage and administration of Levetiracetam for prophylaxis in TBI patients is not well-established, and may vary depending on the specific clinical context. Some key points to consider include:

• Standard dosing regimens: Levetiracetam is typically administered at a dose of 500-1000 mg twice daily, although the optimal dosage for prophylaxis in TBI patients is not well-established 3, 4.
• Loading doses: Some studies have used loading doses of Levetiracetam to rapidly achieve therapeutic levels, although the effectiveness of this approach is not well-established 4.
• Monitoring: Patients receiving Levetiracetam prophylaxis should be closely monitored for signs of seizures, as well as potential side effects such as dizziness, headache, and fatigue 2, 3.