Can Keppra (levetiracetam) cause hematoma formation?

Levetiracetam (Keppra) and Hematoma Formation

Levetiracetam (Keppra) can potentially cause thrombocytopenia, which may increase the risk of hematoma formation, particularly in patients with other risk factors for bleeding.

Mechanism and Evidence

Levetiracetam has been associated with hematological side effects, specifically reduced platelet counts. A cross-sectional study found that patients on levetiracetam monotherapy had significantly lower platelet counts compared to healthy controls 1:

• Platelets were 14% lower (40.68 × 10^9/L reduction) in patients taking levetiracetam
• This effect was observed in both men and women
• No significant difference was found based on sex or age

Clinical Significance and Risk Assessment

The thrombocytopenia associated with levetiracetam could potentially increase bleeding risk, which might contribute to hematoma formation in certain clinical scenarios:

1. Patients with pre-existing bleeding disorders

   • Those with coagulopathies
   • Patients with thrombocytopenia from other causes

2. Patients on anticoagulant or antiplatelet therapy

   • Anticoagulants significantly increase bleeding risk 2
   • Package inserts for anticoagulants like LMWHs include warnings about increased risk of spinal or epidural hematoma 2

3. Patients undergoing surgical procedures

   • Particularly neurosurgical procedures where even minor bleeding can have significant consequences

Management Considerations

For patients requiring levetiracetam who are at increased risk of bleeding:

1. Monitor platelet counts

   • Establish baseline before starting therapy
   • Perform periodic monitoring, especially in high-risk patients

2. Consider alternative antiepileptic drugs if:

   • Patient has pre-existing thrombocytopenia
   • Patient is on anticoagulant therapy
   • Patient has a history of bleeding disorders

3. For patients requiring surgery:

   • Be aware of the potential for reduced platelet counts
   • Consider platelet count assessment before procedures with high bleeding risk

Positive Aspects of Levetiracetam

Despite this potential concern, levetiracetam has shown benefits in patients with intracranial hemorrhage:

• Associated with better cognitive outcomes compared to phenytoin 3
• Lower seizure incidence in ICH patients (0% vs 8% with phenytoin) 3
• Higher Glasgow Coma Scores at dismissal (median 14 vs 11) 3

Conclusion

While levetiracetam can cause thrombocytopenia that theoretically increases hematoma risk, this must be balanced against its efficacy and favorable cognitive profile. For most patients without additional risk factors for bleeding, the benefits likely outweigh this potential risk. However, in patients with multiple risk factors for bleeding or those on anticoagulants, careful monitoring of platelet counts is advisable.