What are the indications for Levetiracetam (Keppra) prophylaxis in traumatic brain injury?

From the Guidelines

Levetiracetam (Keppra) prophylaxis is not recommended for routine use in traumatic brain injury.

Indications for Levetiracetam Prophylaxis

• The use of levetiracetam for primary prevention of post-traumatic seizures can be considered in specific cases with risk factors, such as:
  • Chronic subdural hematoma
  • Past history of epilepsy
• In such cases, levetiracetam is preferred over phenytoin due to its higher degree of tolerance, as suggested by the study 1.

Rationale

• The incidence of early clinical seizures (within 7 days after the brain injury) is relatively low, at 2.2%, and the incidence of delayed seizures (after 7 days) is 2.1% 1.
• Multiple clinical trials and meta-analyses have shown that antiepileptic drugs, including levetiracetam and phenytoin, do not have a significant effect on preventing early or delayed post-traumatic seizures 1.
• The use of antiepileptic drugs has been associated with increased side effects and potentially worsening neurological outcomes 1.

From the Research

Indications for Levetiracetam Prophylaxis in Traumatic Brain Injury

• The use of levetiracetam for early post-traumatic seizure prophylaxis is preferred due to its safety and efficacy 2
• Levetiracetam has demonstrated comparable efficacy to phenytoin for post-traumatic seizure prophylaxis and is associated with fewer adverse effects and monitoring considerations 3
• The Brain Trauma Foundation recommends using phenytoin for early post-traumatic seizure prophylaxis, but levetiracetam may be a reasonable alternative to consider in this patient population 3
• Current guidelines for traumatic brain injury recommend antiepileptic drugs for 7 days after injury to decrease post-traumatic seizure risk, and levetiracetam is an alternative to phenytoin 4

Patient Selection

• Patients with traumatic brain injury who are at risk of early post-traumatic seizures may benefit from levetiracetam prophylaxis 5, 2
• The use of levetiracetam dosing based on Glasgow Coma Scale scores in pediatric traumatic brain injury patients is a novel approach, and dosing accuracy may be increased with use of a PowerPlan 6
• Patients with severe traumatic brain injury may require higher doses of levetiracetam for effective seizure prophylaxis 6

Duration of Prophylaxis

• The recommended duration of levetiracetam prophylaxis is 7 days after traumatic brain injury 2, 3, 4
• However, some patients may receive prophylactic antiepileptic drugs for more than 7 days, despite guideline recommendations 4