An estimated 5-7% of patients experience seizures following traumatic brain injury (TBI). Current guidelines by the Brain Trauma Foundation and the AAN recommend the use of anti-seizure medications limited to the first seven days post-trauma (Brain Trauma Foundation. J Neurotrauma 2007;24(suppl 1); free full supplement at www.braintrauma.org/pdf/protected/Guidelines_Management_2007w_bookmarks.pdf).

A review of antiepileptics for TBI recommends phenytoin since it has been most extensively studied (Torbic et al. Am J Health Syst Pharm 2013;70:759-766). Other agents (e.g. phenobarbital, valproate, carbamazepine) have not been researched to the same degree and are not generally preferred over phenytoin due to their adverse effect profiles. The use of valproate may be associated with increased mortality in TBI.

The authors noted that levetiracetam may be a reasonable alternative to phenytoin for seizure prophylaxis in TBI. However, they added that this agent may be associated with an increased tendency to seizure.

Comment
Dr. Daniel Selchen: Seizure prophylaxis in the context of acute trauma remains a controversial area in spite of the existence of several guidelines/recommendations. Probably the least controversial is the choice of agent – given that phenytoin is the only agent that is easy to load with and much of the risk is immediate/short-term. More controversial are the need for treatment at all in this highly observed group of patients; and the duration of therapy, since the highest risk beyond the first day for some patients may be (as for stroke patients) 6-15 months after the trauma.