What is the best initial management for seizures in an elderly patient with a brain bleed from a fall and potential comorbidities?

Management of Seizures in Elderly Patients with Traumatic Brain Bleed

Treat seizures only when they are clinically or electrographically documented—do not use prophylactic antiseizure medications, as they are associated with increased death and disability without preventing seizures. 1, 2

Initial Assessment and Monitoring

Immediate Evaluation

• Perform urgent head CT to identify the extent of intracranial hemorrhage, mass effect, and any surgically treatable lesions 3
• Assess systolic blood pressure and maintain >110 mmHg, as low blood pressure is a significant mortality risk factor in elderly trauma patients (pooled odds ratio 2.16 for mortality) 1
• Evaluate Glasgow Coma Score, as lower scores predict higher mortality in geriatric trauma 1
• Screen immediately for anticoagulant and antiplatelet medications (warfarin, DOACs, aspirin, clopidogrel), as these significantly increase bleeding risk even after minor trauma 1

EEG Monitoring Indications

• Order continuous EEG monitoring for at least 24-48 hours if the patient has depressed or fluctuating consciousness that is disproportionate to the degree of brain injury or metabolic abnormalities 1, 2
• Recognize that 28% of electrographic seizures are detected after 24 hours, and 94% by 48 hours of monitoring 2
• Understand that 28-31% of select ICH patients have electrographic seizures on continuous EEG despite prophylactic medications 1

Seizure Treatment Algorithm

When to Treat

Initiate antiseizure medication ONLY when:

• Clinical seizures are witnessed or documented 1
• Electrographic seizures are detected on EEG in patients with altered mental status 1, 2
• The seizures are suspected to contribute to impaired consciousness 2

Medication Selection

• Use levetiracetam as first-line therapy due to better tolerability, fewer adverse effects, and lack of significant drug interactions compared to phenytoin 2, 3, 4
• Avoid phenytoin/fosphenytoin entirely, as these agents are associated with increased death and disability in ICH patients 1, 2, 3
• Start levetiracetam at 500 mg IV twice daily, administered over 15 minutes 4
• Increase by 500 mg twice daily every 2 weeks up to maximum 1500 mg twice daily as needed 4

Dosing Adjustments for Elderly Patients

• Adjust dose based on creatinine clearance, as levetiracetam is substantially excreted by the kidney and elderly patients are more likely to have decreased renal function 4
• Monitor renal function closely, as clearance of levetiracetam decreases with impaired renal function 4
• Supplemental doses should be given after dialysis if the patient requires hemodialysis 4

Duration of Treatment

Short-Term Management

• Treat documented seizures for ≤7 days in the perioperative period to reduce seizure-related complications 3
• Do not continue prophylactic antiseizure medications beyond the acute treatment period unless recurrent seizures occur 2, 3

Long-Term Considerations

• Recognize that prophylaxis does not prevent early or late seizures in ICH patients 1, 2
• Understand that early seizures (within 7 days) occur in 2.2% of all TBI cases but up to 38% in acute subdural hematoma 3
• Note that early seizures are not independently associated with worse neurological outcomes or mortality in prospective studies 2

Critical Comorbidity Management

Blood Pressure Control During Seizures

• Maintain systolic blood pressure between 130-150 mmHg using short-acting, titratable IV agents 2
• Avoid aggressive BP reduction below 130 mmHg systolic, as this may critically reduce cerebral perfusion pressure when ICP is elevated 2
• Monitor for hypotension that worsens cerebral perfusion pressure in the setting of elevated ICP 2

Anticoagulation Reversal

• Administer reversal agents for patients on vitamin K antagonists with life-threatening bleeding: give four-factor prothrombin complex concentrates (4F-PCCs) and 5 mg intravenous vitamin K, targeting INR <1.5 1
• For dabigatran-associated uncontrolled bleeding, administer idarucizumab 5 g IV 1
• For rivaroxaban or apixaban-associated life-threatening bleeding, administer andexanet alfa 1

Glucose Management

• Monitor glucose closely and avoid both hyperglycemia and hypoglycemia, as high blood glucose predicts increased mortality and poor outcome independent of diabetes 1

Common Pitfalls to Avoid

• Never use prophylactic antiseizure medications routinely, as they do not prevent seizures and are associated with worse functional outcomes 1, 2
• Never use phenytoin or fosphenytoin, as earlier studies demonstrated these agents are associated with increased death and disability in ICH patients 1, 2, 3
• Do not use risk scores to justify continuation of prophylactic antiseizure drugs beyond 7 days, as there is no evidence they prevent late seizures 2
• Do not assume early seizures worsen outcomes, as prospective studies show they are not independently associated with worse neurological outcomes or mortality 2
• Avoid overly aggressive BP lowering (<130 mmHg systolic), which can critically reduce cerebral perfusion pressure 2

High-Risk Features Requiring Closer Monitoring

• Cortical involvement of the hemorrhage is the most important risk factor for early seizures (up to 16% incidence) 1, 2
• Age ≥74 years increases mortality risk (odds ratio 1.67 compared to 65-74 age group) 1
• Pre-existing comorbidities and polypharmacy (>5 medications) are associated with greater mortality and complications 1
• Patients on warfarin have increased mortality (cumulative odds ratio 1.32) 1