Do cerebellar strokes with hemorrhagic transformation require Levetiracetam (Keppra)?

From the Guidelines

Keppra (levetiracetam) is not routinely required for all cerebellar strokes with hemorrhagic transformation, and its use should be individualized based on the presence of seizures or high risk for developing them. The decision to prescribe Keppra should be guided by the patient's specific clinical presentation and risk factors for seizures. For most cerebellar strokes with hemorrhagic transformation, prophylactic anticonvulsant therapy is not recommended unless there is evidence of seizure activity 1.

Key Considerations

• Cerebellar strokes typically have a lower seizure risk compared to strokes affecting the cerebral cortex because the cerebellum has minimal epileptogenic potential.
• However, if the hemorrhage extends to involve the brainstem or there is significant mass effect, edema, or hydrocephalus, the seizure risk may increase, and closer monitoring for seizure activity is warranted 1.
• In cases where seizures do occur, Keppra is often preferred at an initial dose of 500mg twice daily, which can be titrated up to 1500mg twice daily as needed based on clinical response and seizure control 1.
• The medication should be continued for at least 3-6 months after the last seizure, with potential tapering thereafter under neurological supervision.

Evidence-Based Recommendations

• The use of levetiracetam, fosphenytoin, or valproate in the setting of benzodiazepine-resistant status epilepticus can result in cessation of seizures in approximately half of all patients, with limited harms 1.
• The primary outcome of cessation of status epilepticus and improvement in the level of consciousness at 60 minutes was reached in 47% of patients who received levetiracetam, 45% of patients who received fosphenytoin, and 46% of patients who received valproate 1.

Clinical Implications

• The results of the ESETT study suggest that levetiracetam is a viable option for the treatment of benzodiazepine-resistant status epilepticus, with a favorable safety profile compared to other anticonvulsants 1.
• However, the decision to prescribe Keppra should be individualized based on the patient's specific clinical presentation and risk factors for seizures, rather than being routinely administered to all patients with cerebellar strokes and hemorrhagic transformation.

From the Research

Cerebellar Strokes with Hemorrhagic Transformation and Levetiracetam (Keppra) Use

• The use of Levetiracetam (Keppra) in patients with cerebellar strokes and hemorrhagic transformation is not directly addressed in the provided studies.
• However, studies have investigated the use of Levetiracetam in patients with intracerebral hemorrhage (ICH) and other neurological conditions:
  • A study published in 2022 2 found that Levetiracetam might be effective in preventing acute seizures in patients with ICH.
  • Another study published in 2023 3 suggested that patients may experience a reduced incidence of clinical and electroencephalographic seizures with Levetiracetam dosing >1000-mg total daily dose (TDD).
• The efficacy and optimal dosing of Levetiracetam for seizure prophylaxis in patients with ICH, traumatic brain injury (TBI), supratentorial neurosurgery, and spontaneous subarachnoid hemorrhage (SAH) remain unclear 4.
• A systematic review and meta-analysis published in 2022 4 found that Levetiracetam may be preferred post supratentorial neurosurgery, but the current evidence does not support or refute the use of Levetiracetam prophylaxis in TBI, SAH, or ICH.
• A study published in 2011 5 found that Levetiracetam is associated with improved cognitive outcome for patients with intracranial hemorrhage compared to phenytoin.

Levetiracetam Dosing and Efficacy

• The optimal dosing of Levetiracetam for seizure prophylaxis is unclear, but studies suggest that higher doses (>1000-mg TDD) may be more effective in reducing seizure incidence 3.
• A study published in 2008 6 found that Levetiracetam monotherapy was effective in achieving seizure freedom in patients with late-onset post-stroke seizures, with 77.1% of patients achieving seizure freedom at a daily dose of 1000-3000mg.

Adverse Events and Cognitive Outcomes

• Levetiracetam is generally well-tolerated, with a lower incidence of adverse events compared to other antiseizure medications 4.
• A study published in 2011 5 found that Levetiracetam is associated with improved cognitive outcome for patients with intracranial hemorrhage compared to phenytoin, with higher Glasgow Coma Scores and lower seizure incidence.