Closed Head Injury Medication

Updated: May 04, 2022
  • Author: Leonardo Rangel-Castilla, MD; Chief Editor: Brian H Kopell, MD  more...
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Medication

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]

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Anticonvulsants

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)

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

Phenobarbital (Barbita, Luminal, Solfoton)

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

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