From the Guidelines
Levetiracetam (Keppra) should not be administered as a first-line treatment in cases of intraparenchymal hemorrhage.
Rationale
- The evidence from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group 1 does not specifically recommend Levetiracetam (Keppra) as a first-line treatment for seizures in patients with intraparenchymal hemorrhage.
- Instead, the guidelines suggest using benzodiazepines such as lorazepam or diazepam, followed by intravenous fos-phenytoin or phenytoin to control seizures quickly.
- While a brief period of antiepileptic therapy soon after ICH onset may reduce the risk of early seizures, the choice of medication for prophylaxis should include one that can be administered intravenously as needed during hospitalization and orally after discharge.
- Levetiracetam (Keppra) may be considered for prophylaxis in certain cases, but it is not the preferred initial choice according to the provided evidence.
Key Points
- Seizures occur in approximately 4.2% of patients with intraparenchymal hemorrhage, and 8.1% have seizures within 30 days after onset 1.
- Lobar location is significantly associated with the occurrence of early seizures 1.
- Seizures are independently associated with increased midline shift after intraparenchymal hemorrhage 1.
From the Research
Administration of Levetiracetam in Intraparenchymal Hemorrhage
- The decision to administer prophylactic levetiracetam to patients with intracerebral hemorrhage (ICH) is driven by lobar hematoma location and depressed level of consciousness 2.
- A randomized, double-blind, placebo-controlled trial found that levetiracetam might be effective in preventing acute seizures in intracerebral hemorrhage, with a significant reduction in the occurrence of clinical or electrographic seizures within 72 hours of inclusion 3.
- A systematic review and meta-analysis found that levetiracetam may be preferred post supratentorial neurosurgery, but did not demonstrate significant reductions in seizure incidence in patients with ICH, traumatic brain injury, or spontaneous subarachnoid hemorrhage 4.
- A retrospective cohort study found no statistical difference in seizure incidence, intensive care unit length of stay, hospital length of stay, or adverse events between patients who received prophylactic levetiracetam and those who did not after spontaneous intracerebral hemorrhage 5.
- Another study found that prophylactic anticonvulsant use, primarily levetiracetam, was not associated with worse functional outcome or increased case-fatality in patients with primary ICH 6.
Key Factors Influencing Administration
- Hematoma location (lobar or basal ganglia) and level of consciousness are key factors influencing the decision to administer prophylactic levetiracetam 2.
- Age, initial National Institutes of Health Stroke Scale score, craniotomy, and prior ICH are also independently associated with prophylactic anticonvulsant initiation 6.
Efficacy and Safety
- Levetiracetam may be effective in preventing acute seizures in intracerebral hemorrhage, but larger studies are needed to determine its efficacy and safety 3.
- Adverse events of any severity were reported in a median of 8% of patients given levetiracetam, compared to 21% of patients in comparator groups 4.