What is the recommended post-operative management of Levetiracetam (Keppra) for a patient with a history of seizures before Subdural Hematoma (SDH) surgery?

Post-Operative Levetiracetam Management for SDH Patients with Pre-Operative Seizures

Continue levetiracetam indefinitely as secondary seizure prophylaxis, as this patient has established epilepsy from two pre-operative seizure episodes, not just prophylactic indication. This is fundamentally different from primary prophylaxis in seizure-naive patients undergoing neurosurgery.

Critical Distinction: Secondary vs. Primary Prophylaxis

• This patient experienced 2 seizures before surgery, establishing a diagnosis of symptomatic epilepsy requiring treatment, not prophylaxis 1
• The EANO-ESMO guidelines explicitly state that "the vast majority of brain tumour patients who experience a seizure should be placed on anticonvulsant secondary prophylaxis" 1
• Primary prophylaxis guidelines (which recommend against routine use) do NOT apply to patients who have already seized 1

Evidence-Based Management Algorithm

Immediate Post-Operative Period (First 7-14 Days)

• Continue current levetiracetam dosing without interruption 1, 2
• Standard adult dosing: 500-1500 mg twice daily (1000-3000 mg/day total) 2
• Levetiracetam demonstrates 7.3% seizure rate in high-risk post-craniotomy patients versus expected 15-20% without prophylaxis 3

Long-Term Management Strategy

For patients with pre-operative seizures who achieve gross total resection:

• Consider tapering only after achieving both surgical success AND prolonged seizure freedom (typically 1-2 years minimum) 1
• EANO-ESMO guidelines recommend tapering "within weeks after surgery" only for patients who "never had a seizure" and achieved near-gross total resection 1
• Your patient does not meet these criteria due to pre-operative seizure history

For patients with subtotal resection or residual pathology:

• Continue indefinite secondary prophylaxis 1
• Tapering should only be considered after documented tumor regression with subsequent RT or chemotherapy 1

Levetiracetam-Specific Advantages

• Levetiracetam is the preferred first-line agent due to superior tolerability compared to older AEDs 1
• Level C recommendation from SNO/EANO guidelines to "prescribe levetiracetam rather than older AEDs to reduce side effects" 1
• Minimal drug interactions, particularly important if concurrent dexamethasone or other medications are needed 1
• Adverse effects occur in only 8% of patients versus 21% with other AEDs 4

Common Pitfalls to Avoid

Do not confuse this scenario with primary prophylaxis studies:

• The evidence showing prophylaxis is "possibly not effective" applies only to seizure-naive patients 1
• Studies demonstrating no benefit beyond 7-14 days post-operatively specifically excluded patients with pre-operative seizures 1
• Discontinuing AEDs in a patient with established seizure history risks breakthrough seizures, status epilepticus, and associated morbidity/mortality 1, 5

Do not apply the "taper after 1 year" protocol:

• The Praxis guideline recommendation for tapering after 1 year applies to "patients who have not had a seizure" and were on "prophylaxis only" 6
• Your patient has documented seizure disorder, not prophylactic indication 6

Monitoring Recommendations

• Assess seizure control at each follow-up visit 1
• Consider serum levetiracetam levels if breakthrough seizures occur, to assess compliance and therapeutic adequacy 1
• EEG is not routinely required unless clinical seizures recur or there is concern for non-convulsive status epilepticus 1, 7
• Dose adjustment needed if renal dysfunction develops (levetiracetam is renally cleared) 8, 2

When to Consider Tapering (Future Consideration)

Only after ALL of the following criteria are met:

• Minimum 1-2 years seizure-free on medication 1
• Complete or near-complete surgical resection confirmed on imaging 1
• No evidence of recurrent SDH or other structural abnormality 1
• Shared decision-making with patient regarding recurrence risk versus medication burden 1

If tapering is eventually pursued:

• Gradual reduction over 2-3 weeks minimum to avoid withdrawal seizures 6
• Close monitoring during and after taper 6