Introduction: Levetiracetam is used for seizure prophylaxis after intracranial hemorrhage. Intracranial hemorrhages can be classified based on location of the bleed: extra-axial occurring around the brain tissue and intra-axial occurring within the brain tissue. The goal of this study is to assess the efficacy and safety of levetiracetam for seizure prevention in patients with extra-axial versus intra-axial intracranial hemorrhages.
Methods: A retrospective cohort study was conducted between January 2022 and January 2024 at a community health system. Eligible patients were adults greater than 18 years of age admitted with an intracranial hemorrhage who received at least one dose of levetiracetam. The primary outcome was the incidence of seizure activity in patients with extra-axial versus intra-axial hemorrhages receiving levetiracetam. Secondary outcomes included rate of levetiracetam discontinuation due to side effects, time to first seizure post-injury, intensive care unit and hospital lengths of stay, levetiracetam duration of therapy, documentation of seizure activity 90 days post-discharge and in-hospital all-cause mortality.
Results: One hundred fifty patients were included with 44 patients and 106 patients classified as having intra-axial hemorrhages and extra-axial hemorrhages, respectively. Subdural and subarachnoid hemorrhages predominated in the extra-axial group, while intraparenchymal hemorrhages were most common in the intra-axial group. Seizure activity occurred in 4 and 9 patients who experienced an intra-axial and extra-axial hemorrhage, respectively (9% vs 11%; p value = 0.67). Secondary outcomes including discontinuation due to adverse effects, time to first seizure post-injury, ICU and hospital lengths of stay, levetiracetam duration of therapy and seizure activity 90 days post-injury were not statistically different amongst the two groups. In-hospital all-cause mortality was statistically higher in patients presenting with intra-axial hemorrhages compared to an extra-axial hemorrhage (13 [30%] vs 7 [7%]; p value < 0.05).
Conclusions: Intra-axial intracranial hemorrhages showed significantly higher mortality but no significant difference in seizure rates. Given that under 1% of patients experienced a seizure after 7 days, discontinuing prophylaxis at that point may be reasonable.
