Levetiracetam (Keppra) in Subdural Hemorrhage Management
Levetiracetam is not routinely indicated for prophylactic use in patients with subdural hemorrhage, but it is preferred over phenytoin when seizure prophylaxis is deemed necessary due to specific risk factors. 1
Indications for Levetiracetam in Subdural Hemorrhage
Primary Prophylaxis (No Prior Seizures)
- Primary anticonvulsant prophylaxis is generally not recommended in patients with subdural hemorrhage 1
- However, levetiracetam may be considered in patients with specific risk factors:
- Chronic subdural hematoma requiring surgical treatment 2
- Acute subdural hematoma with midline shift (though with caution as it may have higher risk of electrographic seizures compared to phenytoin) 3
- Past history of epilepsy 1
- Age over 65 years 1
- Initial loss of consciousness or amnesia for more than 24 hours 1
Secondary Prophylaxis (After Seizure Occurrence)
- Levetiracetam is indicated for patients who have already experienced a seizure following subdural hemorrhage 1
- It should be continued until local control of the hemorrhage has been achieved 1
Advantages of Levetiracetam Over Other Anticonvulsants
- Better cognitive outcomes compared to phenytoin in patients with intracranial hemorrhage (higher Glasgow Coma Scores at dismissal) 4, 5
- Lower incidence of adverse effects compared to phenytoin 3, 4
- No significant drug interactions with steroids or other medications commonly used in neurocritical care 1
- Does not require serum level monitoring unlike phenytoin 1
- May be associated with improved functional outcomes compared to phenytoin 5
Dosing Considerations
- Standard dosing is typically 500-1000 mg twice daily 6
- Higher dosing (>1000 mg total daily dose) may be associated with reduced incidence of clinical and electroencephalographic seizures in neurocritical care patients 6
- Most common regimen for higher dosing is 1000 mg twice daily 6
Monitoring and Duration of Therapy
- No routine serum level monitoring is required 1
- Monitor for psychiatric side effects, which can occur in some patients 1
- For subdural hemorrhage patients who have had seizures, continue therapy until local control has been achieved 1
- In patients with chronic subdural hematoma, a mean duration of 8 months of therapy has been reported to be effective 2
Special Considerations
- Patients with impaired or fluctuating level of consciousness disproportionate to their degree of brain injury should be evaluated with continuous EEG for at least 24 hours to detect possible subclinical seizures 1
- Risk scores such as the CAVE score can estimate risk of late seizures (>7 days after hemorrhage), but should not be used alone to guide continuation of antiepileptic drugs 1
- Levetiracetam is preferred over enzyme-inducing anticonvulsants (phenytoin, carbamazepine, phenobarbital) which should be avoided in patients with brain hemorrhage 1
Potential Pitfalls
- Psychiatric side effects can occur with levetiracetam and should be monitored 1
- In patients with midline shift >0 mm, there may be an increased risk of electrographic seizures with levetiracetam compared to phenytoin, despite the overall better safety profile 3
- Discontinuing seizure prophylaxis too early in high-risk patients may lead to breakthrough seizures 2
- Continuing unnecessary prophylaxis in low-risk patients may expose them to medication side effects without clear benefit 1