Antiepileptic prophylaxis in neurosurgical patients: overuse of levetiracetam and the evidence–practice gap

Abstract Objective To review current evidence and guideline recommendations on the use of antiepileptic drugs (AEDs), particularly levetiracetam, for seizure prophylaxis in neurosurgical patients, and to highlight their overuse in clinical practice. Methods A narrative review was conducted using international and Chinese literature, including guidelines from the American Heart Association (AHA), American Academy of Neurology (AAN), Neurocritical care society (NCS), Brain Trauma Foundation (BTF), European Association of Neuro-Oncology (EANO), European Stroke Organization (ESO), and Chinese Neurosurgical Society. Results Evidence indicates limited benefit of prophylactic AEDs in seizure-naïve patients. In major neurosurgical conditions—traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), brain tumors, and elective craniotomy—routine or prolonged levetiracetam prophylaxis is not supported. Short-term administration (≤ 7 days) is justified only for TBI and select perioperative SAH cases. Surveys show widespread over-prescription of levetiracetam beyond guideline recommendations. Conclusion Levetiracetam is frequently overused for seizure prophylaxis in neurosurgery. Strict adherence to guideline-directed indications and duration is essential to improve outcomes and avoid unnecessary adverse effects. Increased education and dissemination of consensus statements are needed globally.