Post-operative seizure prophylaxis after craniotomy: a current evidence and ongoing controversy

Post-operative seizures are a recognized complication following intracranial surgery, with implications for neurologic recovery, length of stay, and quality of life. Despite decades of investigation, the role of routine seizure prophylaxis after craniotomy remains debated. Early trials supported short-term phenytoin use, while recent evidence and guidelines question its necessity in seizure-naïve patients. This review summarizes current data regarding the incidence, risk factors, and prevention of post-craniotomy seizures, with emphasis on the comparative efficacy of antiepileptic agents and the appropriate duration of prophylaxis. Levetiracetam has largely replaced phenytoin in modern practice due to improved tolerability, though neither has shown clear superiority in preventing late seizures. Most data support selective, rather than routine, prophylaxis limited to the immediate postoperative period in high-risk populations. Future work should focus on individualized risk stratification and standardized institutional protocols.