PROCON Study: Preventive Antiepileptic Treatment in Supratentorial Neurosurgery - A Retrospective Before-After Analysis of a Change in Clinical Guidelines.

BACKGROUND

European guidelines published in 2021 discourage the systematic use of prophylactic antiepileptic drugs (AEDs) in seizure-naïve patients with primary or metastatic brain tumors. This study aimed to assess the impact of discontinuing routine AED prophylaxis on postoperative seizure incidence and neurological outcomes.

METHODS

We conducted a single-center retrospective before-after study comparing seizure incidence before and after discontinuation of routine antiepileptic prophylaxis in supratentorial craniotomies. The primary outcome was de novo postoperative seizures. Secondary outcomes included neurological status, associated factors, AED regimens, and adverse events. Univariate analysis was performed; multivariate analysis was not conducted because of the limited number of events.

RESULTS

A total of 382 patients were included. The overall incidence of postoperative seizures following supratentorial craniotomy between 2019 and 2022 was 5.5%. Among patients undergoing supratentorial craniotomy, postoperative seizure incidence decreased from 7.5% in the prophylaxis group to 2.9% in the no-prophylaxis group (P = 0.107). Levetiracetam was the predominant AED. Adverse events related to AEDs were rare (1.5%, P = 0.283). Neurological outcomes at 1 month, including functional autonomy (P = 0.743) and lifestyle (P = 0.460), were not significantly different between the 2 groups. Postoperative seizures were more frequently observed in patients undergoing metastasis resection (P = 0.051) and longer surgical procedures (P = 0.062), though not reaching statistical significance.

CONCLUSIONS

Stopping routine antiepileptic prophylaxis was not associated with increased postoperative seizures or worse neurological outcomes. Further studies are needed to assess the safety of newer AEDs in the postoperative setting.