From the Guidelines
Indications for Levetiracetam Prophylaxis in Traumatic Brain Injury
Prophylaxis with levetiracetam (Keppra) is not generally recommended for primary prevention of post-traumatic seizures in patients with traumatic brain injury, as the evidence suggests that antiepileptic drugs do not significantly reduce the incidence of early or delayed post-traumatic seizures 1. However, it may be considered in patients with specific risk factors, such as chronic subdural hematoma or a past history of epilepsy.
- The use of levetiracetam should be preferred over phenytoin due to its higher degree of tolerance and lower risk of side effects 1.
- In certain cases, such as patients receiving CAR T cell therapy, levetiracetam prophylaxis may be recommended to prevent seizures, particularly in those with CNS disease or a history of seizures, at a dose of 10 mg/kg (up to 500 mg) every 12 hours for 30 days following infusion 1.
- It is essential to weigh the potential benefits and risks of levetiracetam prophylaxis in each patient, considering factors such as the severity of the injury, presence of risk factors, and potential for side effects.
- The decision to use levetiracetam prophylaxis should be made on a case-by-case basis, taking into account the individual patient's circumstances and the latest available evidence 1.
From the Research
Indications for Levetiracetam Prophylaxis in Traumatic Brain Injury
The indications for levetiracetam prophylaxis in traumatic brain injury (TBI) are based on the risk of early posttraumatic seizures (EPTS). According to the studies, the following are the indications for levetiracetam prophylaxis:
- Severe TBI, as defined by a low Glasgow Coma Scale (GCS) score 2, 3
- Combat-related TBI with radiographic evidence of skull fractures or intracranial hemorrhage 3
- TBI patients at high risk for post-traumatic seizures (PTS), such as those with penetrating TBI or transcranial gunshot wounds 3, 4
- Patients with subarachnoid hemorrhage (SAH) or TBI who are at risk for seizures 5
Levetiracetam Dosing Strategies
The optimal dosing strategy for levetiracetam prophylaxis in TBI is not well established. The studies suggest the following:
- A total daily dose (TDD) of levetiracetam greater than 1000 mg may be more effective in reducing the incidence of seizures than a TDD of 1000 mg or less 5, 6
- A dosing strategy based on GCS scores may be effective in pediatric TBI patients 2
- Different dosing strategies, such as ≤ 1000 mg/day, 1500 mg/day, and ≥ 2000 mg/day, may not have a statistically significant difference in the cumulative incidence of early posttraumatic seizures 6
Efficacy and Safety of Levetiracetam Prophylaxis
The efficacy and safety of levetiracetam prophylaxis in TBI are still being studied. The results suggest that:
- Levetiracetam may be effective in reducing the incidence of seizures in TBI patients, but the evidence is not conclusive 3, 5
- Levetiracetam may be safe and well-tolerated in TBI patients, with a low incidence of adverse effects 2, 3, 5
- The incidence of post-traumatic seizures in severe TBI patients may be low, and the benefit of routine prophylactic anticonvulsant therapy may be questioned 4