Postoperative Seizure Prophylaxis in Intracranial Tumors: Evaluating the Role of Anti-Seizure Medication in Seizure-Naïve Patients.

PURPOSE OF REVIEW: Postoperative seizures occur in up to 20% of seizure-naïve adult patients undergoing craniotomy for tumor resection, contributing to morbidity and readmissions. Yet, routine prophylactic use of anti-seizure medications (ASMs) in this population remains unsupported by current evidence-based guidelines. In this review, we synthesize current evidence on seizure incidence, timing, risk factors, and practical perioperative management strategies.

RECENT FINDINGS: Postoperative seizure risk varies by tumor type, cortical involvement, peritumoral edema, hemorrhage, and tumor grade. Across randomized trials and meta-analyses, prophylactic ASM administration has not been shown to consistently reduce postoperative seizure incidence, and older agents can increase toxicity and interaction risk. Some studies suggest a modest reduction of early seizures within the first postoperative week, though this benefit is not sustained long-term. When prophylaxis is employed, second-generation ASMs such as levetiracetam are often favored for their higher tolerability and fewer drug-drug interactions compared to older agents. Emerging evidence has described alternative agents to levetiracetam with greater blood-brain-barrier permeability, but further investigation is required. Routine ASM prophylaxis in seizure-naïve patients undergoing intracranial tumor resection is not supported by current evidence or clinical guidelines. A selective, risk-based approach with short-term prophylaxis may be considered in patients with high-risk features. Future prospective, risk-stratified trials are needed to better define subgroups that may benefit from targeted prophylactic strategies.