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

purpose of reviewPostoperative 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

findingsPostoperative 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.