Keppra Dosing for Post-Stroke Seizures
For new-onset seizures post-stroke, treat acute seizures with lorazepam first-line, followed by levetiracetam 40 mg/kg IV (maximum 2,500-3,000 mg) as a second-line agent if seizures continue, then maintain with 1,000-1,500 mg twice daily for recurrent seizures only—do not use prophylactic anticonvulsants for single self-limiting seizures. 1, 2, 3
Acute Seizure Management in Stroke Patients
Immediate Treatment (Active Seizure)
Administer IV lorazepam 4 mg at 2 mg/min immediately for any actively seizing patient, which has 65% efficacy in terminating status epilepticus. 2
If seizures continue after adequate benzodiazepine dosing, escalate to levetiracetam 30-40 mg/kg IV (approximately 2,000-3,000 mg for average adults) over 5-15 minutes, which achieves 68-73% efficacy in benzodiazepine-refractory seizures. 1, 2, 3
Alternative second-line agents include valproate 20-30 mg/kg IV (88% efficacy, 0% hypotension risk) or fosphenytoin 20 mg PE/kg IV (84% efficacy, but 12% hypotension risk requiring cardiac monitoring). 1, 2
Critical Decision Point: Single vs. Recurrent Seizures
Do NOT initiate long-term anticonvulsants for a single, self-limiting seizure occurring within 24 hours of stroke onset. 1 This is a common pitfall—immediate post-stroke seizures are considered provoked and do not require chronic treatment.
Monitor these patients for recurrent seizure activity during routine vital sign checks. 1
Only treat with maintenance anticonvulsants if seizures recur or if multiple seizures occur in the early post-stroke period (up to 4 weeks). 1
Maintenance Dosing for Recurrent Post-Stroke Seizures
Standard Maintenance Regimen
Start levetiracetam 1,000 mg twice daily for patients with recurrent post-stroke seizures, which achieved seizure freedom in 54.3% of elderly post-stroke patients in prospective studies. 4
Increase to 1,500 mg twice daily if seizures persist (effective in an additional 20% of patients). 4
Maximum dose is 3,000 mg daily (1,500 mg twice daily), though doses up to 3,000 mg/day may be used in refractory cases. 5, 4
Evidence Supporting Higher Dosing
Recent critical care data demonstrates that higher maintenance doses (750-1,000 mg twice daily, median 25 mg/kg/day) are more than twice as likely to achieve therapeutic levels compared to low-dose regimens (500 mg twice daily), and reduce seizure odds by 68%. 6 This challenges traditional conservative dosing in elderly stroke patients.
Only 45% of patients receiving 500 mg twice daily achieved target therapeutic levels (12-46 μg/mL), compared to 64% receiving higher doses. 6
Consider starting at 1,000 mg twice daily rather than 500 mg twice daily, particularly in patients with normal renal function. 6
Renal Dose Adjustments
Levetiracetam requires dose reduction in renal dysfunction because 66% is renally eliminated. 7, 5
| Creatinine Clearance | Dosage | Frequency |
|---|---|---|
| >80 mL/min (Normal) | 500-1,500 mg | Every 12 hours |
| 50-80 mL/min (Mild) | 500-1,000 mg | Every 12 hours |
| 30-50 mL/min (Moderate) | 250-750 mg | Every 12 hours |
| <30 mL/min (Severe) | 250-500 mg | Every 12 hours |
| ESRD on dialysis | 500-1,000 mg | Every 24 hours* |
*Give supplemental dose after dialysis 2
- For patients on continuous venovenous hemofiltration (CVVH), consider 1,000 mg every 12 hours with therapeutic drug monitoring, as clearance approximates normal patients. 7
Critical Pitfalls to Avoid
Never use prophylactic anticonvulsants in stroke patients without seizures. 1 There is evidence suggesting possible harm with negative effects on neurological recovery. 1
Do not underdose in acute seizure management. The full 40 mg/kg loading dose (2,500-3,000 mg) is required for status epilepticus, not lower prophylactic doses. 3
Avoid attributing all post-stroke altered mental status to the stroke itself. Consider EEG monitoring if unexplained reduced consciousness persists, as non-convulsive seizures are common in stroke patients. 1
Advantages of Levetiracetam in Stroke Patients
Minimal drug interactions, particularly important in stroke patients on anticoagulants, antiplatelets, and statins. 5
No hepatic metabolism, making it safer in elderly patients with multiple comorbidities. 5
Rapid oral bioavailability (100%) allows transition from IV to oral without dose adjustment. 5
Well-tolerated in elderly, with 77% achieving seizure freedom in post-stroke populations. 4
Most common adverse effects are somnolence, dizziness, and asthenia, which occurred in only 11.4% requiring discontinuation in post-stroke patients. 4
Monitoring Requirements
Check levetiracetam serum levels if breakthrough seizures occur to assess compliance and adequacy of dosing (target 12-46 μg/mL). 6
Steady-state is achieved in 2 days with twice-daily dosing. 5
Consider EEG if seizures persist despite therapeutic levels or if non-convulsive status epilepticus is suspected. 1