How to manage a 71-year-old male with subdural hematoma (SDH) status post craniotomy, encephalopathy, and seizures on Keppra (levetiracetam) who is becoming combative?

Management of Combative Behavior in a Post-Craniotomy Patient with SDH, Encephalopathy, and Seizures on Levetiracetam

For a 71-year-old male with subdural hematoma status post craniotomy who is developing combative behavior while on levetiracetam, the most appropriate management approach is to consider switching to valproate (30 mg/kg IV) as it has demonstrated similar efficacy to levetiracetam for seizure control with potentially fewer psychiatric side effects.

Assessment of Current Situation

• Combative behavior in this patient may be related to levetiracetam therapy, as psychiatric side effects are a known concern with this medication 1
• Post-craniotomy patients with SDH are at risk for seizures, with reported incidence ranging from 0.7-18.5% 2
• The patient's encephalopathy may be exacerbated by medication side effects, underlying neurological injury, or possibly undetected seizure activity 1

Evaluation Steps

• Rule out nonconvulsive status epilepticus with EEG monitoring, as worsening neurological symptoms or vigilance problems could represent ongoing seizure activity 1
• Assess for other treatable causes of altered mental status including:
  • Metabolic disturbances (hypoglycemia, hyponatremia, hypoxia)
  • Drug toxicity or interactions
  • Systemic or CNS infection
  • Recurrent or new intracranial hemorrhage 1

Management Options

1. Antiseizure Medication Adjustment

• First option: Switch from levetiracetam to valproate

  • Valproate has demonstrated efficacy similar to levetiracetam (68% vs 73% seizure cessation) with potentially fewer psychiatric side effects 1
  • Recommended loading dose: 30 mg/kg IV infused at 5-6 mg/kg per hour 1
  • Maintenance: 1-2 mg/kg per hour infusion 1

• Alternative option: Consider lamotrigine

  • Has good antiseizure activity with favorable psychiatric side effect profile 1
  • Drawback: Requires several weeks to reach therapeutic levels 1

• Avoid phenytoin/fosphenytoin

  • Associated with excess morbidity and mortality in patients with intracranial hemorrhage 1
  • Only 56% success rate in terminating status epilepticus in studies 1

2. Sedation Options for Acute Management

• For severe agitation requiring immediate intervention:
  • Propofol can be considered if patient requires intubation (2 mg/kg bolus followed by 3-4 mg/kg/hr infusion) 1
  • Midazolam may be used for short-term management of agitation 1

3. Monitoring and Follow-up

• Continuous EEG monitoring is reasonable to detect subclinical seizures, especially in high-risk patients 1
• Regular assessment of serum drug levels to ensure therapeutic range and evaluate for toxicity 1
• Monitor for improvement in mental status and behavior after medication adjustment 1

Special Considerations

• Post-craniotomy patients are at higher risk for seizures in the first week after surgery, with highest risk in the first 24 hours 3
• Patients with significant midline shift prior to surgery have higher risk of postoperative seizures (OR 1.13,95% CI 1.01-1.26) 4
• Periodic lateralized epileptiform discharges (PLEDs) can occur 1-9 days after evacuation of subdural hematomas and may be associated with altered consciousness and seizures 5

Pitfalls to Avoid

• Don't assume combative behavior is solely psychiatric - rule out ongoing seizure activity, especially nonconvulsive status epilepticus 1
• Don't continue levetiracetam if psychiatric side effects are suspected - psychiatric adverse effects are a known concern with this medication 1
• Don't use phenytoin for seizure prophylaxis in patients with intracranial hemorrhage due to associated excess morbidity 1
• Don't overlook the possibility of recurrent hemorrhage as a cause of altered mental status in post-craniotomy patients 1