Is levetiracetam (Keppra) suitable for a patient with a history of cerebral aneurysm and stroke?

Levetiracetam Use in Patients with Cerebral Aneurysm and Stroke History

Levetiracetam is appropriate and well-tolerated for seizure management in patients with a history of cerebral aneurysm and stroke, and should be the preferred antiepileptic drug in this population due to its favorable safety profile and minimal drug interactions. 1

Evidence Supporting Use in Stroke Patients

• Levetiracetam monotherapy has demonstrated efficacy in elderly patients with late-onset poststroke seizures, with 82.4% achieving seizure freedom at doses of 1000-2000 mg daily over a mean follow-up of 17.68 months 2

• The drug was well-tolerated in this stroke population, with only 20.6% experiencing side effects and only one patient discontinuing due to severe somnolence 2

• Levetiracetam has excellent pharmacokinetic properties approaching those of an ideal antiepileptic drug, with minimal drug interactions—a critical advantage in stroke patients who are typically on multiple medications including anticoagulants and antihypertensives 3, 4

Safety Profile in Neurovascular Disease

• For patients with intracranial aneurysms or arteriovenous malformations, levetiracetam is safer than older antiepileptic drugs because it does not increase bleeding risk and has minimal cardiovascular effects 1

• Levetiracetam has a lower frequency of potentially life-threatening hypotension (0.7%) compared to valproic acid (1.6%), which is particularly important in patients with cerebrovascular disease where blood pressure management is critical 5

• Arrhythmias occurred in only 0.7% of patients receiving levetiracetam, making it cardiovascularly safer than alternatives 5

Dosing Recommendations

• Standard dosing should be 1000 mg twice daily (2000 mg total daily dose) rather than lower doses, as patients receiving >1000 mg total daily dose had significantly lower seizure incidence compared to those receiving 1000 mg total daily dose 6

• Dose adjustments may be necessary in patients with renal dysfunction, as levetiracetam is renally cleared 1

• For seizure prophylaxis in high-risk neurovascular patients, consider 10 mg/kg (up to 500 mg) every 12 hours for 30 days following acute events 1

Advantages Over Alternative Antiepileptic Drugs

• Levetiracetam should be chosen over older antiepileptic drugs (phenytoin, carbamazepine) to reduce side effects in brain injury patients, with fewer adverse drug reactions and higher retention rates 1

• Unlike valproic acid, levetiracetam does not cause thrombocytopenia or hepatotoxicity—complications that could be particularly problematic in patients with cerebrovascular disease who may require anticoagulation or antiplatelet therapy 1

• Levetiracetam has no enzyme-inducing properties, avoiding interactions with warfarin, statins, and other medications commonly used in stroke patients 3

Important Caveats

• The most serious adverse effects are behavioral in nature (agitation, mood changes, anxiety) and may be more common in patients with pre-existing psychiatric or neurobehavioral problems 3

• Monitor for behavioral changes, particularly in the first few weeks of therapy, and consider dose reduction or alternative agents if significant psychiatric symptoms emerge 3

• While levetiracetam is generally well-tolerated, approximately 8% of patients experience adverse events of any severity 7

Clinical Algorithm for This Patient

1. Initiate levetiracetam at 1000 mg twice daily (2000 mg total daily dose) 6
2. Assess renal function and adjust dose if creatinine clearance is reduced 1
3. Monitor for behavioral side effects during the first 2-4 weeks 3
4. If seizures are not controlled, increase to 1500 mg twice daily (3000 mg total daily dose) rather than switching agents 6
5. Continue indefinitely if seizures have occurred; for prophylaxis only, consider discontinuation after 30 days if no seizures develop 1