Practice parameter: Antiepileptic drug prophylaxis in severe traumatic brain injury

Abstract

Abstract-Objective:To review the evidence regarding antiepileptic drug (AED) prophylaxis in patients with severe traumatic brain injury (TBI) in order to make practice recommendations. Methods: The authors identified relevant studies by searching multiple databases and reviewing reference lists of other sources. They included studies that prospectively compared post-traumatic seizure rates in patients given AED prophylaxis vs controls. Each study was graded (class I to IV) according to a standard classification-of-evidence scheme and results were analyzed and pooled. Results: Pooled class I studies demonstrated a significantly lower risk of early post-traumatic seizures (those occurring within 7 days after injury) in patients given phenytoin prophylaxis compared to controls (relative risk 0.37, 95% CI 0.18 to 0.74). Pooled class I and class II studies demonstrated no significant difference in the risk of late post-traumatic seizures (those occurring beyond 7 days after injury) in patients given AED prophylaxis compared to controls (relative risk 1.05, 95% CI 0.82 to 1.35). Serum AED levels were suboptimal in these studies and adverse effects were mild but frequent. Conclusions: For adult patients with severe TBI, prophylaxis with phenytoin is effective in decreasing the risk of early post-traumatic seizures. AED prophylaxis is probably not effective in decreasing the risk of late post-traumatic seizures. Further studies addressing milder forms of TBI, the use of newer AEDs, the utility of EEG, and the applicability of these findings to children are recommended.

The Utility of EEG, SSEP, and Other Neurophysiologic Tools to Guide Neurocritical Care

“…Although investigators have reported a negligible seizure frequency when using the Lund concept method of preventing elevations in intracranial pressure, the success may be attributable to midazolam use as part of a bias to use sedation to prevent intracranial hypertension rather than the intracranial pressure control itself [29]. As a result, the literature supports the routine use of continuous monitoring for seizure detection in patients with TBI, despite the small amount of prevention afforded by 7 days of prophylactic phenytoin [30]. A secondary role of EEG in TBI is discrimination of seizures from paroxysmal autonomic instability with dystonia, both of which may be associated with elevated intracranial pressure [31,32].…”

Can idiosyncratic drug reactions occur in quick succession? a case of cross sensitivity between levetiracetam and phenytoin

“…There is still a difference of opinion amongst the physicians for the use of AEDs to prevent PTS after traumatic brain injury. 2 AEDs have a beneficial role if used in the first week after traumatic brain injury.…”

“…The prophylaxis with AEDs beyond the first week is more likely to be associated with adverse effects. 2 Idiosyncratic drug reactions are unpredictable immune mediated reactions, which are dose independent and can be life threatening. The skin, liver and blood cells are the most common targets, though they can affect other organs as well.…”

“…1 The use of AEDs for the prophylaxis of such seizures has its own risk of adverse effects. 2 As AEDs have a narrow therapeutic range, they are more likely to cause adverse effects with diverse manifestations. Here we report a case of a young female with head injury as a result of motor vehicular accident, on seizure prophylaxis, developing adverse drug reactions (ADRs) to AEDs one after the other.…”

New thoughts on first seizure

“…11 Additionally, AED therapy after a single or infrequent seizures does not affect longterm development of epilepsy. [10][11][12][13][14] If seizures are related to provoking factors such as metabolic disturbance or drugs, the provoking factor should be removed or treated and AEDs are not indicated. Similarly, alcohol withdrawal seizures should not be treated with longterm AEDs, but management should address the alcohol misuse and the risks carried by alcohol withdrawal.…”