From the Guidelines
Levetiracetam (Keppra) is not recommended for primary prevention of post-traumatic seizures in patients with acute subdural hematomas, except in cases with specific risk factors such as chronic subdural hematoma or past history of epilepsy. The management of severe traumatic brain injury, including acute subdural hematomas, does not suggest the use of antiepileptic drugs for primary prevention to reduce the incidence of post-traumatic seizures 1.
Key Points
- The incidence of early clinical seizures within 7 days after brain injury is 2.2%, and the incidence of delayed seizures after 7 days is 2.1% 1.
- Risk factors for delayed clinical seizures include brain contusion, acute subdural hematoma, 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, and none of them found a significant effect of antiepileptic drugs in preventing 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.
Clinical Considerations
- The primary management of acute subdural hematomas focuses on surgical evacuation when indicated, blood pressure control, and other measures to control intracranial pressure.
- Seizure prophylaxis may be considered in high-risk patients, but the use of antiepileptic drugs should be individualized based on the patient's specific risk factors and medical history.
- Levetiracetam is often preferred over older antiepileptic drugs like phenytoin due to its more favorable side effect profile and fewer drug interactions 1.
From the Research
Levetiracetam (Keppra) Use in Acute Subdural Hematomas
- Levetiracetam is used for seizure prophylaxis in patients with acute subdural hematomas (SDHs) 2
- A study comparing levetiracetam and phenytoin for seizure prophylaxis following acute or subacute SDH diagnosis found that levetiracetam had a similar efficacy to phenytoin in preventing clinical and/or electrographic seizures, but was associated with a lower risk of adverse drug effects 2
- However, in patients with midline shift >0 mm, levetiracetam was associated with an increased risk of electrographic seizures during hospitalization 2
Management of Acute Subdural Hematomas
- The management of acute SDH typically conforms to the Advanced Trauma Life Support protocol, with airway taking priority, and management of breathing and circulation occurring in parallel rather than sequence 3
- Urgent surgical hematoma evacuation is necessary for most patients with subdural hematoma, but well-orchestrated, evidenced-based, multidisciplinary, postoperative critical care is essential to achieve the best possible outcome 3
- A prospective, observational, comparative effectiveness study found that a treatment strategy preferring acute surgical evacuation over initial conservative treatment was not associated with better functional outcome in patients with acute subdural haematoma 4
Treatment Options for Acute Subdural Hematomas
- Treatment options for acute subdural hematomas include surgical evacuation, decompressive craniectomy, and conservative treatment 5, 4
- A case report described the use of the Subdural Evacuating Port System (SEPS) for the treatment of subdural hematoma in the emergency department, which provides a minimally invasive technique to drain subdural hematomas 6