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Guidelines for Seizure Prophylaxis in Patients Undergoing Supratentorial Neurosurgery: A Statement for Healthcare Professionals from the Neurocritical Care Society

Neurocritical Care Society · 2026 · USA

Source and licence

Authors
A. Shaun Rowe, Jamie Ullman, Emily L. Johnson et al.
Title
Guidelines for Seizure Prophylaxis in Patients Undergoing Supratentorial Neurosurgery: A Statement for Healthcare Professionals from the Neurocritical Care Society
Journal
Neurocritical Care, 2026
DOI
10.1007/s12028-026-02522-2
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC13369652

Licence statement of the original publication

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Results

  • Should anti-seizure medication versus no anti-seizure medication be used in patients hospitalized for supratentorial neurosurgery in patients with no history of clinical or electrographic seizures?Level of recommendation,quality (certainty) of evidence: Should anti-seizure medication versus no anti-seizure medication be used in patients hospitalized for supratentorial neurosurgery in patients with no history of clinical or electrographic seizures?
  • We suggest that clinicians may choose to use either ASM or not use ASM for seizure prevention in patients undergoing supratentorial neurosurgery, as the balance of benefits and harms is uncertainLevel of recommendation,quality (certainty) of evidence: Conditional recommendation, low certainty of evidence
  • If an anti-seizure medication is used, should LEV or PHT be preferentially used for supratentorial neurosurgery in patients with no history of clinical or electrographic seizures?Level of recommendation,quality (certainty) of evidence: If an anti-seizure medication is used, should LEV or PHT be preferentially used for supratentorial neurosurgery in patients with no history of clinical or electrographic seizures?
  • When prophylactic ASM is used for supratentorial craniotomy, we suggest LEV over PHTLevel of recommendation,quality (certainty) of evidence: Conditional recommendation, very-low certainty of evidence
  • If an anti-seizure medication is used, should a long (> 7 days) versus short (≤ 7 days) duration of prophylaxis be used for supratentorial neurosurgery in patients with no history of clinical or electrographic seizures?Level of recommendation,quality (certainty) of evidence: If an anti-seizure medication is used, should a long (> 7 days) versus short (≤ 7 days) duration of prophylaxis be used for supratentorial neurosurgery in patients with no history of clinical or electrographic seizures?
  • If a prophylactic ASM is used for supratentorial craniotomy, we suggest a short duration (≤ 7 days) vs. a longer duration (> 7 days) of useLevel of recommendation,quality (certainty) of evidence: Conditional recommendation, very-low certainty of evidence
  • We suggest that clinicians may choose to use ASM or not use ASM for seizure prevention in patients undergoing supratentorial neurosurgery, as the balance of benefits and harms is uncertainconditional recommendation, low certainty of evidence

Abstract

Background: There is significant heterogeneity related to the use of prophylactic antiseizure medications (ASM) following supratentorial craniotomy.

Methods: We conducted a systematic review and meta-analysis assessing ASM primary prophylaxis in adults hospitalized following supratentorial neurosurgery with no prior seizure history. The following population, intervention, comparator, and outcome (PICO) questions were assessed: (1) Should ASM versus no ASM be used as seizure prophylaxis in adult patients undergoing supratentorial neurosurgery? (2) If an ASM is used, should levetiracetam (LEV) or phenytoin/fosphenytoin (PHT) be preferentially used? and (3) Should a long (> 7 days) versus short (≤ 7 days) duration of prophylaxis be used? The main outcomes were early seizure (≤ 14 days), late seizures (> 14 days), adverse events, mortality, and functional and cognitive outcomes. We utilized Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to generate recommendations.

Results: The initial literature search yielded 1988 articles, and 16 formed the basis of the recommendations. PICO 1: while meta-analysis of randomized controlled trials (RCTs) demonstrated a significant benefit for early seizure prevention, meta-analyses including all study designs was nonsignificant. Further, there were no differences in late seizure or mortality rates, and there was a trend toward higher adverse event rates with ASM. PICO 2: LEV was associated with significantly lower early seizure rates than PHT, and there were trends toward fewer late seizures and adverse events with LEV. PICO 3: only three studies examined the duration of ASM treatment, and there was no significant difference in seizure events between subjects treated for a short versus long duration.

Conclusions: We suggest that either prophylactic ASM or no ASM be used for seizure prophylaxis in patients undergoing supratentorial neurosurgery (conditional recommendation, low quality of evidence). If an ASM is used, we suggest LEV over PHT (conditional recommendation, very low quality of evidence) for a short duration (conditional recommendation, very low quality of evidence).

Supplementary Information: The online version contains supplementary material available at 10.1007/s12028-026-02522-2.

Contents of the original publication

The section headings of the original.

  • Introduction
  • Methods
  • Panel Composition
  • PICO Generation
  • Study Population
  • Inclusion and Exclusion Criteria
  • Search Strategy
  • Study Screening and Data Collection
  • Risk of Bias and Certainty of Evidence Evaluation
  • Statistical Analyses
  • Development of Recommendations
  • Results
  • Discussion
  • Conclusions

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