Should prophylactic Keppra (levetiracetam) be given for subdural hematoma (SDH)?

Prophylactic Levetiracetam for Subdural Hematoma

Prophylactic antiepileptic drugs are not recommended for patients with subdural hematomas who have not experienced seizures. 1, 2

Evidence Against Prophylactic Antiepileptic Use

The evidence strongly discourages routine prophylactic antiepileptic drug administration in patients with subdural hematomas:

• The American College of Anaesthesia explicitly recommends against prophylactic antiepileptic drugs in patients with subdural hematomas who have not experienced seizures 2
• Clinical guidelines state: "We do not suggest using antiepileptic drugs for primary prevention to reduce the incidence of post-traumatic seizures" with a Grade 2- recommendation and strong agreement 1
• The risk of seizures in patients with isolated subdural hematomas and preserved consciousness is remarkably low (2.2% during hospitalization) 3

Risk Assessment for Seizures

While prophylaxis is generally not recommended, certain factors may influence seizure risk in SDH patients:

• Hematoma thickness is significantly associated with seizure risk (OR 1.16, p=.005) 3
• Other risk factors for post-traumatic seizures include:
  • Brain contusion
  • Acute subdural hematoma
  • Skull fracture
  • Initial loss of consciousness or amnesia >24 hours
  • Age >65 years
  • Craniectomy 1

If Seizure Prophylaxis Is Deemed Necessary

In rare situations where risk factors strongly suggest the need for prophylaxis:

• Levetiracetam is preferred over phenytoin due to:

  • Better side effect profile 1, 2
  • Lower risk of adverse drug effects (p<0.001) 4
  • No significant difference in clinical seizure prevention efficacy compared to phenytoin 4
  • Avoidance of drug interactions with steroids and other medications 1

• Dosing considerations:

  • Higher doses of levetiracetam (>1000mg total daily dose) may be more effective than lower doses (1000mg total daily dose) for seizure prophylaxis (p=0.01) 5

Common Pitfalls to Avoid

• Assuming all subdural hematomas require seizure prophylaxis
• Continuing prophylactic antiepileptic drugs beyond the acute period without clear indication
• Using phenytoin as first-line therapy due to its side effect profile and drug interactions
• Overlooking potential psychiatric side effects with levetiracetam 1, 2

Monitoring Recommendations

If prophylactic treatment is initiated:

• Monitor for behavioral side effects with levetiracetam
• Consider EEG monitoring in patients with depressed neurological examination or fluctuating level of consciousness
• Discontinue prophylaxis if no seizures occur during the acute period

Remember that the evidence does not support routine prophylactic antiepileptic use in SDH patients, and treatment decisions should be based on individual risk factors rather than standard practice.