Medication Summary

Neurosurgeons have commonly given prophylactic anticonvulsants to individuals with intracranial hemorrhage. The appropriate duration of treatment is not well established. Individuals who have experienced seizure activity can reasonably be treated with anticonvulsants for 6-12 months, after which reevaluation is necessary. Temkin and colleagues suggest that treatment for longer than 8 days after injury does not reduce the frequency of long-term seizure disorders. Anticonvulsants may be used to treat early (< 7 days) posttraumatic seizures. According to Greenberg, prophylactic anticonvulsants do not reduce the frequency of late (≥7 days) posttraumatic seizures.^[96]

The anticonvulsant medication recommended for adults is phenytoin or fos-phenytoin (18 mg/kg of loading dose), ensuring therapeutic levels of 10-20 mg/dL. Note that a "therapeutic level" does not necessarily have a direct bearing on adequate control of seizures. A relatively common adverse effect of long-term phenytoin use is gingival hyperplasia and hirsutism, which precludes long-term use in children. Phenobarbital is an acceptable alternative for children who require long-term anticonvulsive therapy (10-20 mg/kg loading dose, then 3-5 mg/kg/day divided bid/tid) to achieve a therapeutic level of 10-40 mg/dL.

The antiepileptic drug levetiracetam is used in the setting of acute brain injury for seizure treatment or prophylaxis; it is a desirable alternative to phenytoin and is associated with fewer complications when used as monotherapy. Checking for therapeutic levels is not needed. The dose is 500 mg bid IV or PO and is advanced to 1000 mg bid.^[97] A review of management approaches to TBI conducted to promote best clinical practice found that for seizure management, levetiracetam appears to be as effective as phenytoin, but the optimal dose remains unclear. Review authors state that there has been a lack of clear outcome benefit for any individual osmotherapy agent, with no difference in mortality or neurologic recovery. They recommend that further research is needed to determine the optimal package of care and interventions for patients with TBI. Future studies should focus on patient-centered outcome measures such as long-term neurologic recovery and improved quality of life.^[98]

Class Summary

These agents are indicated for short-term (1 week) or long-term (6- to 12-month) posttraumatic seizure control for patients who have experienced posttraumatic seizure activity. Phenobarbital may be considered as long-term anticonvulsive therapy for children.

Phenytoin (Dilantin)

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Used as acute seizure prophylaxis for individuals with closed head injuries.

Phenobarbital (Barbita, Luminal, Solfoton)

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Used as acute seizure prophylaxis for children with closed head injuries.

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Media Gallery

CT scan of left frontal acute epidural hematoma (black arrow) with midline shift (white arrow). Note the left posterior falx subdural hematoma and left frontoparietal cortical contusion.
CT scan of left frontoparietal acute subdural hematoma (black arrow). Note the moderate amount of midline shift.
CT scan of bilateral acute intraventricular hemorrhages (black arrow). Note the comminuted skull fractures that involve bilateral frontal, temporal, and parietal bones (white arrow). Note the ischemic changes in both frontal lobes, subarachnoid hemorrhages in the intrahemispheric fissure and left frontal lobe, and multiple intraparenchymal hemorrhages in both frontal poles.
MRI of the brain that shows diffuse axonal injury (DAI) and hyperintense signal in the corpus callosum (splenium), septum pellucidum, and right external capsule.
MRI of the brain (sagittal view) that shows a Duret hemorrhage in the splenium of the corpus callosum.
Cerebral blood flow/cerebral perfusion pressure chart.

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Table 1. American Academy of Neurology Concussion Grading Scale

Grade 1	Grade 2	Grade 3
Transient confusion	Transient confusion	...
No loss of consciousness	No loss of consciousness	Brief or prolonged loss of consciousness
Concussive symptoms or mental status change resolving within 15 minutes	Concussive symptoms or mental status change resolving after 15 minutes	...

Table 2. Glasgow Coma Scale

Best Motor Response	Obeying commands	6
	Localizing	5
	Withdrawal (abnormal flexion)	4
	Flexion (decorticate posturing)	3
	Extension (decerebrate posturing)	2
	No response	1
Verbal Response	Oriented	5
	Confused	4
	Using inappropriate words	3
	Making incomprehensible sounds	2
	No response	1
Eye Opening	Spontaneous	4
	To command	3
	To pain	2
	No response	1
Total		3-15

Table 3. Advantages and Disadvantages of CT Scanning in Head Trauma Evaluation

Advantages	Disadvantages
Noninvasive and rapid	Traumatic vascular lesions may be missed.
Very sensitive for acute hemorrhage	DAI is likely to be missed.
Defines nature of ICH* (ie, SDH^†, SAH^‡)	Motion artifact may limit study.
Defines anatomic location of lesion	Posterior fossa lesions are poorly depicted.
Identifies fractures of the cranium	Depressed skull fractures at the vertex (or along the plane of an axial scan) are poorly depicted.
Sensitive to detecting intracranial air	The scanner has a weight limit, and a patient may be too heavy.
Sensitive in identifying foreign objects	A patient may decompensate while in the scanner.
*Intracranial hemorrhage. ^†Subdural hemorrhage. ^‡Subarachnoid hemorrhage.

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Author

Leonardo Rangel-Castilla, MD Fellow in Cerebrovascular and Skull Base Neurosurgery, Barrow Neurological Institute

Leonardo Rangel-Castilla, MD is a member of the following medical societies: American Association of Neurological Surgeons, Congress of Neurological Surgeons, Neurocritical Care Society

Disclosure: Nothing to disclose.

Coauthor(s)

Jaime Gasco, MD Staff Physician, Department of Neurosurgery, University of Texas Medical Branch School of Medicine

Jaime Gasco, MD is a member of the following medical societies: American Association of Neurological Surgeons, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Fadi Hanbali, MD, FACS Associate Professor, Division of Neurosurgery, Department of Surgery, Texas Tech University Health Sciences Center; Associate Professor, Department of Orthopedic Surgery, Texas Tech University Health Sciences Center; Adjunct Professor, Departments of Neurosurgery and Orthopedic Surgery, Division of Neurosurgery, University of Texas Medical Branch

Fadi Hanbali, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Paul Salinas, MD Resident Physician, Department of Neurosurgery, University of Texas Medical Branch at Galveston

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ryszard M Pluta, MD, PhD (Retired) Associate Professor, Neurosurgical Department Medical Research Center, Polish Academy of Sciences, Poland; (Retired) Clinical Staff Scientist, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH); (Retired) Fishbein Fellow, JAMA

Ryszard M Pluta, MD, PhD is a member of the following medical societies: Congress of Neurological Surgeons, Polish Society of Neurosurgeons

Disclosure: Nothing to disclose.

Chief Editor

Brian H Kopell, MD Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai

Brian H Kopell, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons, International Parkinson and Movement Disorder Society, North American Neuromodulation Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from Abbott Neuromodulation for consulting; Received Consulting Fee from ClearPoint Neuro.

Additional Contributors

Paul L Penar, MD, FACS Professor, Department of Surgery, Division of Neurosurgery, Director, Functional Neurosurgery and Radiosurgery Programs, University of Vermont College of Medicine

Paul L Penar, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, World Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.