Single-Dose Intraoperative Perampanel Infusion During Awake Glioma Surgery for Potential Prophylaxis of Intraoperative and Early Postoperative Seizures: A Case Report and Literature Review

Intraoperative and early postoperative seizures are among the most critical complications associated with awake craniotomy for diffuse glioma resection. Although current guidelines do not routinely recommend prophylactic antiseizure medications (ASMs) for awake craniotomy, they are frequently used in clinical practice. However, the optimal choice of ASM remains unclear, particularly for seizure-naïve patients. Perampanel, a selective and non-competitive antagonist of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid-type glutamate receptors, has recently become available in an intravenous formulation. Its potential role as an intraoperative ASM during awake glioma surgery has not been previously explored. In this report, we present the first documented case of single-dose intravenous perampanel administration for potential seizure prophylaxis in awake glioma surgery. The patient was a 35-year-old woman with a left insular diffuse glioma who underwent awake craniotomy using the asleep-awake-asleep technique. A 6 mg intravenous dose of perampanel was administered at the beginning of surgery. She was awakened approximately 3.5 hours post-administration and completed motor and language tasks without difficulty. The awake phase lasted approximately 4.5 hours, during which no clinical or electrographic seizures occurred. No adverse effects, including dizziness or somnolence, were observed. Serum perampanel concentrations increased within 1-3 hours and remained elevated for one week after a single infusion (110-200 ng/mL). The concentration observed in this case was lower than the previously reported therapeutic range (200-600 ng/mL). This case represents the first reported instance of intravenous perampanel administered intraoperatively during awake glioma surgery, without significant adverse effects either during the procedure or in the early postoperative period. Its rapid therapeutic onset and sustained efficacy suggest potential utility for seizure prophylaxis in awake glioma surgery. However, further studies with larger patient cohorts are warranted to validate efficacy and establish optimal dosing strategies.