Global Variation in Antiepileptic Prophylaxis in Neurosurgery: Assessing Guideline Adherence and Identifying Barriers

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Farag¹, Waeel O. Hamouda², Ramez W. Kirollos³, Sameh E. Hassan⁴, and 19 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9543079/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: Although guidelines exist for prophylactic antiepileptic drug (AED) use in neurosurgery, their application in clinical practice varies, and adherence among practitioners is not well-characterized. This study aimed to evaluate global neurosurgical practices regarding AED prescribing, assess guideline awareness and adherence, and identify barriers contributing to practice variation. Methods: A 26-item, cross-sectional, web-based survey was distributed internationally to practising neurosurgeons. The questionnaire assessed demographic characteristics, familiarity with established guidelines, prescribing patterns across major neurosurgical pathologies (traumatic brain injury, brain tumours, subarachnoid haemorrhage, intraparenchymal haemorrhage, and post-craniotomy states), and perceived obstacles to guideline implementation. Descriptive statistics and chi-square analyses were performed to evaluate associations between professional characteristics and prescribing behaviour. Results: A total of 310 neurosurgeons from multiple continents completed the survey. Although 77.4% reported awareness of existing AED guidelines, only 30.6% considered themselves highly familiar with their content. Levetiracetam was the most frequently prescribed AED (76%), yet prophylactic prescribing patterns differed substantially among the surveyed pathologies, including conditions where routine prophylaxis is not recommended. Guideline deviation was common: 51.6% reported, sometimes departing from recommendations, primarily due to patient-specific factors (48.4%) and reliance on personal clinical experience (43.5%). Consultants were significantly more likely than trainees to deviate based on experiential judgment (P = .042). Two-thirds of respondents perceived current recommendations as insufficient, and 98.4% expressed a need for enhanced educational support. Conclusions: A substantial evidence–practice gap persists in the prophylactic use of AED in neurosurgery. Awareness of guidelines does not reliably translate into adherence, and prescribing decisions are frequently influenced by experiential and contextual factors. The findings underscore the need for clearer, harmonised, and accessible recommendations supported by targeted educational strategies to reduce unwarranted variability and optimise patient outcomes. Antiepileptic drugs Seizure prophylaxis Traumatic brain injury Brain neoplasms Intracranial hemorrhage Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Introduction In the neurosurgical population, seizures are a well-recognized complication that may develop following traumatic brain injury (TBI), brain tumors, spontaneous intracranial hemorrhage (ICH), or cranial surgical interventions [ 1 – 6 ]. Consequently, antiepileptic drugs (AEDs) are commonly administered to prevent or manage seizures in neurosurgical patients [ 7 – 12 ]. Nonetheless, routine AED prophylaxis in seizure-naïve neurosurgical patients lacks strong supporting evidence, and most guidelines recommend it only for high-risk individuals [ 13 – 23 ]. Despite these efforts, Guideline implementation is inconsistent, with substantial variation in AED prescribing. Factors contributing to this include resource availability, adoption of newer AEDs, and dependence on personal clinical experience [ 24 – 30 ]. Such variability in clinical practice may result in inadequate protection for high-risk patients while simultaneously exposing others to unnecessary medication-related adverse effects. [ 31 – 35 ]. The primary objective of this global survey was to evaluate the current state of AED use among neurosurgeons by assessing: 1) awareness and familiarity with existing guidelines, 2) current prescribing practices across common neurosurgical pathologies, and 3) perceived barriers to guideline adherence. Methods Study Design and Participant Recruitment A global, cross-sectional online survey targeting neurosurgeons at various professional levels (consultants, associate consultants, registrars, and residents) was performed. The survey was disseminated over a six-month period via social media platforms and direct email. Participation was voluntary and anonymous. Survey Development and Data Collection A 26-item questionnaire was developed using Google Forms®. The survey was structured into four domains: Demographic and professional background. Knowledge and awareness of AED guidelines. AED prescription practices for neurotrauma, brain tumors, SAH, post-craniotomy, and IPH. Adherence to guidelines, perceived barriers, and educational needs. The questionnaire utilized multiple-choice, checklist, and free-text response formats. Statistical Analysis We summarized data with descriptive statistics (frequencies and percentages) and used chi-square tests to explore associations between categorical variables. (e.g., reasons for guideline deviation by professional role). A P- value of < .05 was considered statistically significant. Qualitative data from open-ended responses were analyzed using inductive thematic analysis by two independent reviewers. Ethical Considerations The study protocol received approval from the Institutional Review Board of KAMC. Electronic consent was obtained prior to participation. Results Participant Demographics and Professional Characteristics (Table 1 ) All 310 respondents completed the survey. The cohort was predominantly male (93.5%, n = 290). Geographically, most participants were based in the Middle East and North Africa (56.5%, n = 175), followed by Asia (17.7%, n = 55) and Europe (12.9%, n = 40); smaller proportions were from Latin America (7.0%, n = 22), North America (4.9%, n = 15), and Australia and the Pacific region (1.0%, n = 3) (Fig. 1 ). Nearly half of respondents were consultants (46.8%, n = 145), followed by registrars (24.2%, n = 75), junior residents (17.7%, n = 55), and associate consultants (11.3%, n = 35). The majority identified as general neurosurgeons (88.7%, n = 275). Most participants worked in academic or university hospitals (45.2%, n = 140), with others based in public/community hospitals (35.5%, n = 110), private practice (16.1%, n = 50), and military hospitals (3.2%, n = 10). A large proportion reported more than five years of clinical experience (80.6%, n = 250). In terms of workload, 72.6% (n = 225) managed more than 10 inpatient cases per week, while outpatient activity was substantial, with 45.2% (n = 140) seeing more than 30 outpatients weekly. Table 1 summarizing participant demographics and professional characteristics: Characteristic Category Number (n) Percentage (%) Total respondents – 310 100 Gender Male 290 93.5 Female 20 6.5 Region Middle East & North Africa 175 56.5 Asia 55 17.7 Europe 40 12.9 North America 15 4.9 Latin America 22 7 Australia and Pacific region 3 1 Position / Level Consultant 145 46.8 Registrar 75 24.2 Junior resident 55 17.7 Associate consultant 35 11.3 Type of neurosurgeon General 275 88.7 Other / subspecialty 35 11.3 Hospital type Academic / University 140 45.2 Public / Community 110 35.5 Private practice 50 16.1 Military 10 3 Years of experience > 5 years 250 80.6 ≤ 5 years 60 19.4 Inpatient workload 30 patients/week 140 45.2 ≤ 30 patients/week 170 54.8 Table 1 . Summary of participant demographics and professional characteristics. Knowledge and Awareness of Guidelines Although the majority of neurosurgeons reported being aware of existing antiepileptic drug (AED) guidelines (77.4%, n = 240), a notable proportion (22.6%, n = 70) indicated a lack of awareness. However, only 30.6% (n = 92) considered themselves highly familiar with the guideline content. The most commonly cited guidelines were those issued by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons (51.6%, n = 160), followed by the Brain Trauma Foundation (37.0%, n = 115), and the National Institute for Health and Care Excellence (14.5%, n = 45). In contrast, smaller groups reported relying on senior colleagues (17.7%, n = 55), local institutional protocols (6.5%, n = 20), or other national and international society recommendations. Regarding levels of familiarity (Fig. 2 ), 30.6% (n = 92) described themselves as very familiar, 50% (n = 155) as somewhat familiar, 16% (n = 50) as not familiar, and 3.3% (n = 13) stated that they did not follow any guidelines. These findings highlight a discrepancy between general awareness and actual familiarity with guideline content (Fig. 3 ). Only one-third of respondents (33.9%, n = 105) reported receiving periodic continuing medical education updates or notifications related to these recommendations. When questioned about whether existing guidance sufficiently addressed all clinical scenarios, the largest proportion of respondents felt that it did not (38.7%, n = 120), while 24.2% (n = 75) believed the coverage was adequate and the remainder were uncertain (Fig. 4 ). The clinical areas most frequently perceived as insufficiently addressed included post-craniotomy management (50.0%, n = 155), brain tumours (40.3%, n = 125), neurotrauma (38.7%, n = 120), and subarachnoid haemorrhage (27.4%, n = 85) (Fig. 5 ). AED Prescription Practices Neurotrauma Among 310 respondents, AED prophylaxis based on TBI severity was variable. For mild TBI, 9.7% (n = 30) prescribed AED, while 45.2% (n = 140) did so for moderate TBI, and 48.4% (n = 150) for severe TBI according to GCS. Notably, 40.3% (n = 125) did not use GCS as a criterion for decision-making. When considering injury location or mechanism, prophylaxis was more frequently applied. Specifically, 33.9% (n = 105) prescribed AED for epidural hemorrhages, 71% (n = 220) for subdural, 69.4% (n = 215) for subarachnoid, 72.6% (n = 225) for cerebral intraparenchymal hemorrhages, and 24.2% (n = 75) for cerebellar hemorrhages. AED were also prescribed for depressed skull fractures by 56.5% (n = 175), diffuse axonal injury by 35.5% (n = 110), pneumocephalus by 37% (n = 115), brainstem hemorrhage by 8% (n = 24), and non-depressed fractures by 4.8% (n = 15). Meanwhile, 14.5% (n = 45) did not consider injury location in their decisions. Patient age influenced AED prescription in only 11.3% (n = 35) of respondents, whereas 84% (n = 260) did not factor age into their decision. In contrast, maternity status had a stronger impact, with 61.3% (n = 190) considering pregnancy, childbearing, or breastfeeding status. Regarding prophylaxis duration, 54.8% (n = 170) prescribed AED for one week when no posttraumatic seizures were documented. For immediate posttraumatic seizures (< 12 hours), 25.8% (n = 80) used AED for one week, 43.5% (n = 135) for 1–12 months, and 11.5% (n = 35) based duration on EEG findings. For early seizures ( 7 days) were mainly guided by EEG in 29% (n = 90) of respondents, with durations ranging from 3–6 months 9.7% (n = 30), 6–12 months 22.6% (n = 70), and 12–24 months 17.7% (n = 55). Other Pathologies For newly diagnosed, non-operated brain tumors, AED prophylaxis was most commonly prescribed for supratentorial intra-axial tumors (66.1%, n = 205) and supratentorial extra-axial tumors (40.3%, n = 125), whereas infratentorial tumors were less frequently treated (11.3%, n = 35). AED were sometimes used only if epileptic activity developed (40%, n = 125) or were not prescribed at all (11.3%, n = 35). Intraoperative reloading after mannitol-induced diuresis was reported as “yes” by 33.9% (n = 105), “no” by 37% (n = 115), and “sometimes” by 33.9% (n = 105). The typical postoperative AED duration varied: 16% (n = 50) prescribed for 1–3 months, while others tailored the duration according to surgical extent (8%, n = 25), histology (8%, n = 25), tumor site (14.5%, n = 45), EEG findings (30.6%, n = 95), or absence of seizures (29%, n = 90). For aneurysmal subarachnoid hemorrhage (SAH), prophylactic AED were prescribed selectively in high-risk scenarios, including high Hunt and Hess scale (17.7%, n = 55), high WFNS score (8%, n = 25), modified Fisher scale ≥ 3 (9.7%, n = 30), associated hematoma (3.2%, n = 10), infarction (42.2%, n = 75), sylvian SAH (9.7%, n = 30), fluctuating neurological status (12.9%, n = 40), or if open surgery was performed (14.5%, n = 45). Overall, AED were prescribed in all SAH cases by 53.2% (n = 165), while 21% (n = 65) never prescribed prophylaxis. The preferred duration ranged from 1 week (14.5%, n = 45) to 1 month (11.3%, n = 35), 1–3 months (11.3%, n = 35), 3–6 months (11.3%, n = 35), 6–12 months (4.8%, n = 15), EEG-guided (21%, n = 65), or never (11.3%, n = 35). In intraparenchymal hemorrhage (IPH), AED were most commonly prescribed for lobar cortical hemorrhages (66%, n = 205) or deep IPH (12.9%, n = 40), with cerebellar IPH treated in 4.8% (n = 15) and GCS/hematoma-based prescription in 11.3% (n = 35). EEG-guided use occurred in 16% (n = 50), while 19.4% (n = 60) never prescribed AED routinely. Duration ranged from 1 week (16%, n = 50) to 1–3 months (9.7%, n = 30), 3–6 months (12.9%, n = 40), 6–12 months (4.8%, n = 15), 12–24 months (9.7%, n = 10), longer durations depending on clinical context (3.2%, n = 15), more than 24 months (3.2%, n = 10), follow-up EEG (16%, n = 50), or occurrence of seizures (27.4%, n = 85). Drug Preference and Monitoring Levetiracetam was the most commonly prescribed AED (76%, n = 235), followed by Phenytoin (19.4%, n = 60), while other AED were used less frequently. Regarding adverse events influencing patient compliance, 54.8% (n = 170) considered Levetiracetam safest, followed by Phenytoin 21% (n = 65) and Valproate 16% (n = 50) (Fig. 6 ). Serum AED levels were routinely monitored by 25.8% (n = 80), never monitored by 21% (n = 65), sometimes monitored by 32.3% (n = 100), and monitored only for specific drugs by 21% (n = 65). AED Withdrawal Practices A majority of clinicians (84%, n = 260) considered AED withdrawal after a patient had been seizure-free for a specified period. Withdrawal was guided by EEG in 61.3% (n = 190) or radiological resolution in 21% (n = 65), with patient preference influencing 1.6% (n = 5). The preferred seizure-free intervals were 3–6 months (24.2%, n = 75), 6–12 months (25.8%, n = 80), 12–24 months (22.6%, n = 70), and 1–4 weeks (17.7%, n = 55). EEG guidance was commonly used by 54.8% (n = 170), focusing on normal background activity (24.2%, n = 75), absence of epileptiform discharges (67.7%, n = 210), and resolution of prior abnormalities (29%, n = 90). Limitations to EEG use included unavailability (14.5%, n = 45), operator dependence (17.7%, n = 55), false negatives (30.6%, n = 95), and insufficient evidence (24.2%, n = 75). Other factors influencing withdrawal included patient preference (25.8%, n = 80), AED side effects (54.8%, n = 170), prior cranial surgery (27.4%, n = 85), persistent brain pathology (27.4%, n = 85), patient occupation (19.4%, n = 60), and injury site (43.5%, n = 135). Adherence to Guidelines and Perceived Barriers Deviation from clinical guidelines for AED use was common. Over half of respondents reported sometimes departing from recommendations (51.6%, n = 160), while 16.0% (n = 50) reported often deviating. In contrast, 22.6% (n = 70) indicated that they rarely deviated, 6.4% (n = 20) reported always deviating, and only 3.3% (n = 10) stated that they never departed from guideline recommendations (Fig. 7 ). Consultants were significantly more likely than trainees to deviate on the basis of personal clinical experience (52.2% vs 29.4%; P = .042). The most commonly cited reasons for deviation were patient-specific clinical factors (48.4%, n = 150) and reliance on personal clinical experience (43.5%, n = 135). Additional contributing factors included the presence of multiple or conflicting guidelines (38.7%, n = 120), lack of familiarity with recommendations (25.8%, n = 80), limited supporting evidence (24.2%, n = 75), institutional resource constraints (22.6%, n = 70), and concerns regarding adverse effects (Fig. 8 ). From a systems perspective, the main barriers to effective guideline implementation were AED availability and cost (30.6%, n = 95) and patient non-compliance (14.5%, n = 45) (Fig. 9 ). Interdisciplinary Collaboration and Educational Needs The degree of neurology involvement in AED prescribing varied among respondents. Only 6.6% (n = 20) reported always consulting neurology, while 27.4% (n = 85) consulted very often, 37% (n = 115) sometimes, and 29% (n = 90) rarely. When consultation was discretionary, neurologists were most frequently involved for patients with pre-existing epilepsy (51.6%, n = 160), refractory seizures (82.3%, n = 255), AED-related adverse effects (51.6%, n = 160), long-term AED therapy (35.5%, n = 110), or during AED weaning plans (38.7%, n = 120). A minority of respondents (6.5%, n = 20) reported never consulting neurology. Almost all participants (98.4%, n = 305) expressed a desire for additional education and training on optimal AED use. Online webinars were the preferred learning modality (66%, n = 205), followed by concise guideline summaries (50%, n = 155). Some respondents also recommended self-directed online modules, regular email updates summarising key recommendations or featuring case-based discussions, and the development of a mobile application to assist with AED prescribing as strategies to improve awareness of, and adherence to, clinical guidelines. Discussion Our findings reveal continued variation and uncertainty in AED prophylaxis practices among neurosurgeons, reflecting trends reported in previous multicenter studies [ 8 , 25 – 28 ]. These findings suggest that heterogeneity in prescribing practices remains a global issue despite the availability of guideline-based recommendations. While participants were from several continents, the sample was weighted toward the MENA region, limiting global representativeness. Therefore, the findings should be interpreted as reflecting broad international input rather than strictly global representativeness. The substantial contribution from the MENA offers insight into a neurosurgical community that has historically been underrepresented in survey-based research. In addition, responses were collected from multiple continents and diverse practice environments, enhancing the international scope of the dataset. Importantly, to our knowledge, this is among the first surveys to comprehensively evaluate antiepileptic prescribing practices across the full spectrum of neurosurgical conditions rather than focusing on a single pathology. Evidence Base and Recommendations Contemporary systematic reviews and major professional society guidelines generally discourage routine prophylactic AED administration in seizure-naïve patients with conditions such as SAH, ICH, TBI, or newly diagnosed brain tumors, except in selected high-risk circumstances [ 13 – 23 , 36 – 38 ]. The SNO/EANO and AAN guidelines specifically advise against routine prophylaxis, emphasizing that decisions should not be based on tumor location, histology, or molecular features due to a lack of predictive value [ 21 , 22 , 37 , 38 ]. Similarly, for traumatic brain injury and other neurosurgical pathologies, the evidence supporting routine prophylactic AED is equivocal, and clinical judgment remains paramount [ 13 – 20 , 39 – 41 ]. Persistent Practice Variation and Guideline Gaps Despite existing guidelines, considerable uncertainty remains about the timing, choice of agents, and duration of AED prophylaxis. Several surveys have assessed antiepileptic prescribing patterns in brain-tumour surgery over the past two decades; however, their use in other neurosurgical conditions has not been explored, likely because guidelines in those areas are viewed as more established compared with brain-tumour surgery [ 8 , 25 – 27 ]. In our study, 66.1% of neurosurgeons prescribed AED prophylactically for newly diagnosed supratentorial intra-axial tumors without prior seizures, closely mirroring the 63% who "always or almost always" prescribed prophylaxis in the AANS/CNS survey. This consistency across different study populations and time periods underscores the persistent nature of this clinical dilemma, even a decade later [ 25 ]. A 2005 survey from the United States by Siomin et al. reported that 70% of neurosurgeons routinely used AED prophylaxis after craniotomy, with the highest use in intra-axial tumors [26). In contrast, data from the United Kingdom showed far lower adoption, as 59% of surgeons never prescribed AED for glioma surgery and 79% avoided them in meningioma resections [ 42 ]. More recently, a U.S. pharmacy-claims analysis demonstrated that 40.7% of patients undergoing brain-tumor resection or biopsy received postoperative AED prophylaxis. Usage was highest in open supratentorial intraparenchymal tumor resections (62.5%) and much lower for infratentorial cases (9.7%). Levetiracetam was the predominant agent (78.5%), followed by phenytoin (20.5%) [ 28 ]. A recent Italian survey examined postoperative AED practices among neurosurgeons, gathering responses from 82 clinicians representing half of the country’s neurosurgical units. More than half reported routinely prescribing AED to seizure-free patients, with supratentorial tumor location being the main determinant. Levetiracetam was used almost universally (97.7%), and 23.8% maintained therapy for more than six months. After early postoperative seizures, nearly all participants (96.3%) initiated treatment. Only 4 surgeons (5.1%) routinely stopped AED within one month, whereas 32 (40.5%) extended therapy beyond six months. Remarkably, fewer than half (48.7%) involved a neurologist in managing AED decisions [ 8 ]. Taken together, when aggregating data from the previously published surveys summarized in Table 2 , approximately 80% of clinicians—practicing across diverse regions worldwide—reported routinely prescribing postoperative antiepileptic medications following tumor resection. Beyond brain tumors, our survey captured practice patterns in neurotrauma, ICH, and SAH—areas where the evidence base is considered more established—and still demonstrated marked variability in both indications and duration of prophylaxis. This variation suggests that even in areas with clearer guidelines, adherence is not universal. Levetiracetam has consistently been reported as the first-line AED across recent surveys (75.8% in our cohort, compared with 85% in Dewan et al. and 97.7% in Pascarella et al.). This trend marks a notable shift from earlier surveys, in which phenytoin predominated [ 26 ]. The comparatively lower rate observed in our study may reflect the fact that most respondents practice in North Africa and the Middle East, where resource limitations can influence AED selection. Across all studies—including our own—clinicians frequently continue prophylactic AED beyond two weeks [ 8 , 25 – 27 ]. Prolonged AED administration continues, even though evidence for its effectiveness in preventing late seizures or improving outcomes remains limited [ 13 – 23 , 36 – 38 , 42 – 44 ]. Moreover, collective literature consistently highlights the absence of consensus on optimal treatment duration in many clinical scenarios, a critical knowledge gap that directly impacts patient care [ 8 , 25 – 28 ]. Table 2 provides a summary of surveys evaluating prophylactic AED use in neurosurgery. Authors & Year Target Specialty, (No. of Responders), location of practice spectrum Prescribing Frequency Primary Agent Duration of AED Administration Brouwers et al., 2003 Medical oncology, neurology, radiation oncology, neurosurgery (122), practicing in Ontario, Canada Brain tumour Always (22%), Sometimes (48%), Never (30%) Unspecified Unspecified Siomin et al., 2005 General neurosurgery, members of AANS (386), location of practice not specified Brain tumour Routinely > 70% Phenytoin ~ 1 week (18%), 2–6 weeks (35%), > 6 weeks (36%) Dewan et al., 2016 Neurosurgery, oncology, AANS/CNS tumour section members (133), practicing in 16 countries, and 5 continents Brain tumour Always (63%), Sometimes (9%), Never (28%) Levetiracetam (85%) ~ 1 week (25%), 2–6 weeks (37%), > 6 weeks (13%) Pascarella et al., 2023 Adult and pediatric neurosurgeons (82), practicing in Italy Brain tumour 52.1% routinely prescribe AED post-craniotomy Levetiracetam (97.6%) 23.8% continue > 6 months; after early seizures: 40.5% continue > 6 months Current Global Survey, 2025 Neurosurgeons (310), practicing worldwide Brain tumour TBI, ICH, SAH Varied widely according to pathology Levetiracetam (75.8%) Varied widely according to pathology Table 2 . Summary of surveys evaluating prophylactic antiepileptic drug (AED) use in neurosurgery. Barriers to Guideline Adherence Our findings, in line with quality improvement studies, suggest that the major barriers to guideline adherence include lack of awareness, perceived guideline complexity, patient-specific factors and reliance on personal or institutional experience [ 45 ]. The significant finding that consultants more frequently rely on personal experience suggests that as neurosurgeons mature, they may develop their own practice patterns that supersede published recommendations. This is compounded by the infrequent collaboration with neurologists, potentially limiting exposure to specialized epilepsy management expertise. The reliance on senior colleagues and local institutional guidelines as primary sources, as reported by our respondents, further underscores this culture of experiential learning over strict guideline adherence. Importantly, although prophylactic AED are routinely prescribed by most surgeons in both our survey and prior studies, significant uncertainty remains regarding their true effectiveness. In the AANS/CNS survey, 62% of participants either doubted or were unsure whether prophylactic AED actually reduced postoperative seizures [ 25 ], highlighting the same evidence-practice gap we observed, where clinicians often rely on personal experience rather than guideline recommendations. This issue is especially pertinent for brain tumor patients, as the AAN and CNS guideline advises against routine prophylaxis [ 38 , 46 ], a recommendation that continues to generate debate. The persistently high rates of prophylaxis reported in our survey and previous studies—despite skepticism and guideline advice—suggest a combination of defensive medicine and a deeply entrenched institutional culture that remain difficult to change. Our respondents also indicated that tools such as online webinars, self-paced digital courses, periodic emails summarizing guidelines or presenting case-based discussions, and a mobile application to support AED prescribing could enhance guideline awareness and adherence. Such initiatives could contribute to reducing unwarranted AED prescribing, lowering costs, minimizing treatment-related adverse effects, and ultimately enhancing overall patient quality of life. Agent Selection and Adverse Effects Levetiracetam has emerged as the preferred agent because of its favorable side-effect profile and minimal drug interactions, particularly when compared with older AED such as phenytoin [ 47 ], factors that may contribute to its widespread—and potentially excessive—use among neurosurgeons. Nevertheless, Levetiracetam is associated with psychiatric and behavioral adverse effects in approximately 10–25% of patients (e.g., irritability, agitation, aggression, emotional lability, depression), with severe manifestations such as psychosis or suicidality occurring in about 1–2% of cases [ 48 , 49 ]. Symptoms typically emerge within the first 2–6 weeks of treatment or following rapid dose escalation [ 32 ]. Risk factors include pre-existing psychiatric disorders (e.g., depression, anxiety), female sex, recreational drug use, polytherapy, and rapid titration [ 32 ]. These factors should be evaluated prior to initiating Levetiracetam to determine the risk of psychiatric complications, which might warrant selecting an alternative antiepileptic drug. Although most psychiatric adverse effects are reversible, this does not justify unnecessary or prolonged prescription. Extended or inappropriate use increases treatment costs, medication burden, and the risk of additional adverse effects without improving clinical outcomes [ 50 ]. Need for Further Research and Unified Guidelines The absence of robust, large-scale randomized controlled trials continues to hinder the development of clear, evidence-based practice standards [ 37 ]. This underscores the pressing need for multicenter studies to better define the effectiveness of seizure prophylaxis and guide future recommendations. In the meantime, care must rely on a multidisciplinary, patient-focused strategy that integrates existing evidence with clinical expertise and individual patient preferences. The overwhelming demand for enhanced education (98.4% in our survey) and the request for streamlined protocols signal a strong directive for the neurosurgical field. Collaborative efforts between neurology and neurosurgery societies could be instrumental in meeting this need by increasing awareness, developing evidence-based practice standards, and promoting joint strategies aimed at reducing the routine use of AED. Future perspective Further investigations incorporating prescribing audits and linkage to patient outcomes are warranted to determine the clinical impact of observed practice variation. Study Limitations The results of this study should be interpreted in light of several limitations. A probability-based sampling approach was not achievable, and although the total number of respondents is comparable to or larger than many single-centre surveys, the predominance of participants from MENA region may limit the generalizability of the findings to truly global neurosurgical practice. Nevertheless, the substantial representation from the MENA region offers important perspectives from a neurosurgical community that has been relatively underrepresented in previous survey-based studies. As with all clinician-administered surveys, responses reflect reported rather than independently audited practice patterns. The voluntary nature of participation introduces potential self-selection bias, as neurosurgeons with stronger interest in seizure prophylaxis may have been more likely to respond. Although the questionnaire was informed by existing literature and underwent expert review to support content validity, it remains subject to the inherent constraints of clinician-administered survey instruments. Despite these limitations, participation across multiple continents and practice environments provides a broad perspective on contemporary neurosurgical attitudes toward seizure prophylaxis. Conclusion This international survey highlights a considerable opportunity to improve the quality of care for neurosurgical patients. Narrowing the gap between evidence and clinical practice necessitates a focused effort to create clear, consensus-based guidelines and implement them via targeted, accessible educational strategies appreciated by both trainees and experienced surgeons. The recurring patterns observed across multiple surveys underscore that this variability in practice constitutes a core challenge in neurosurgical care, calling for coordinated solutions through high-quality clinical trials and more effective guideline dissemination. Abbreviations AAN – American Academy of Neurology AANS – American Association of Neurological Surgeons AED – Antiepileptic Drug BTF – Brain Trauma Foundation CNS – Congress of Neurological Surgeons EANO – European Association of Neuro-Oncology EEG – Electroencephalogram GCS – Glasgow Coma Scale ICH – Intracerebral Haemorrhage / Intracranial Haemorrhage IPH – Intraparenchymal Haemorrhage KAMC – King Abdullah Medical City MENA – Middle East and North Africa NCS – Neurocritical Care Society SAH – Subarachnoid Haemorrhage SNO – Society for Neuro-Oncology TBI – Traumatic Brain Injury DAI – Diffuse Axonal Injury Declarations Data availability The datasets generated and/or analysed during the current study are not publicly available due to restrictions on data sharing but are available from the corresponding author on reasonable request. Acknowledgments The authors thank all the neurosurgeons who participated in this survey. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or non-profit sectors. Author Contributions Ahmed A. Farag: Conceptualization, Methodology, Investigation, Data curation, Formal analysis, Project administration, Writing – original draft. Waeel O. Hamouda: Conceptualization, Methodology, Supervision, Writing – review & editing. Ramez W. Kirollos: Methodology, Validation, Writing – review & editing. Sameh E. Hassan: Investigation, Data curation, Writing – review & editing. Hussein Kheshaifati: Investigation, Data curation, Writing – review & editing. Mohammad G. Abdoh: Investigation, Data curation, Writing – review & editing. Sultan Al-Saiari: Supervision, Validation, Writing – review & editing. Mubasher A. Mir: Methodology, Validation, Writing – review & editing. Essam M. Rezk: Supervision, Writing – review & editing. Yoseri J. Alhamss: Investigation, Data curation, Writing – review & editing. Abdelmoneim A. Kamar: Investigation, Data curation, Writing – review & editing. Abdulrahman A. Alshamrani: Investigation, Data curation, Writing – review & editing. Faisal A. Sukkar: Investigation, Data curation, Writing – review & editing. Alaaeldein Nagy: Data curation, Writing – review & editing. Mohamed M. Ismail: Data curation, Writing – review & editing. Muhamad F. Thamrin: Data curation, Writing – review & editing. Abdelazim L. Sadaka: Investigation, Writing – review & editing. Mohamed Okasha: Validation, Writing – review & editing. Mohamed A. Khoudir: Validation, Writing – review & editing. Yahya M. Mir: Investigation, Data curation, Writing – review & editing. Waleed M. Alzahrani: Validation, Clinical input, Writing – review & editing. Asmaa A. Abdelaziz: Data curation, Writing – review & editing. Khalid Al-Orabi: Conceptualization, Supervision, Writing – review & editing. Conflict of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. References Sconzo, D., Wadhwa, A., Balagurunath, K., Berube, M., Enriquez-Marulanda, A., Wetsel, Z., Ravina, K., & Binello, E. 1259 Predictors of Seizures in Patients Post Op From Surgical Intervention for Traumatic Brain Injury. Neurosurgery. 2025; 71. https://doi.org/10.1227/neu.0000000000003360_1259. Imsamer, A., Sitthinamsuwan, B., Tansirisithikul, C., & Nunta-Aree, S. Risk factors of posthemorrhagic seizure in spontaneous intracerebral hemorrhage. Neurosurgical Review. 2025; 48. https://doi.org/10.1007/s10143-025-03229-2. Fordington, S., & Manford, M. A review of seizures and epilepsy following traumatic brain injury. Journal of Neurology. 2020; 267. https://doi.org/10.1007/s00415-020-09926-w. Ersoy, T., Ridwan, S., Grote, A., Coras, R., & Simon, M. 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Pharmacological management of post-traumatic seizures in adults: current practice patterns in the UK and the Republic of Ireland. Acta Neurochirurgica. 2018; 161. https://doi.org/10.1007/s00701-018-3683-9 Uribe, A., Zuleta-Alarcón, A., Kassem, M., Sandhu, G., & Bergese, S. Intraoperative Seizures: Anesthetic and Antiepileptic Drugs.. Current pharmaceutical design. 2018; 23 42. https://doi.org/10.2174/1381612823666171024154026. Turnbull, D., Singatullina, N., & Reilly, C. A Systematic Appraisal of Neurosurgical Seizure Prophylaxis: Guidance for Critical Care Management. Journal of Neurosurgical Anesthesiology. 2015; 28. https://doi.org/10.1097/ana.0000000000000206. Jenkinson MD, Ali A, Islim AI, Helmy A, Grant R. Letter to the Editor. Establishing the role of prophylactic antiepileptic drugs in glioma and meningioma surgery. J Neurosurg 2019;131(3):985–7. https://doi.org/10.3171/2019. Wang YC, Chuang CC, Tu PH, Wei KC, Wu CT, Lee CC, et al. Seizures in surgically resected atypical and malignant meningiomas: long-term outcome analysis. Epilepsy Res 2018;140:82–9. https://doi.org/10.1016/j.eplepsyres.2017.12.013. Joiner EF, Youngerman BE, Hudson TS, Yang J, Welch MR, McKhann GM, et al. Effectiveness of perioperative antiepileptic drug prophylaxis for early and late seizures following oncologic neurosurgery: a meta-analysis. J Neurosurg 2018;130 (4):1274–82. https://doi.org/10.3171/2017.10.JNS172236. Fu, D., Kong, X., Veenema, T., Bota, D., & Koirala, B. Adherence to Prophylactic Anticonvulsant Guidelines for Newly Diagnosed Brain Tumor Patients: A Quality Improvement Study. Journal of the Advanced Practitioner in Oncology. 2022; 13. https://doi.org/10.6004/jadpro.2022.13.8.4. Chen CC, Rennert RC, Olson JJ. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Prophylactic Anticonvulsants in the Treatment of Adults with Metastatic Brain Tumors. Neurosurgery . 2019;84(3):E195-E197. doi:10.1093/neuros/nyy545. Lee CH, Koo HW, Han SR, Choi CY, Sohn MJ, Lee CH. Phenytoin versus levetiracetam as prophylaxis for postcraniotomy seizure in patients with no history of seizures: systematic review and meta-analysis. J Neurosurg 2019;130(6): 2063–70. https://doi.org/10.3171/2018.4.JNS1891. Cramer JA, De Rue K, Devinsky O, Edrich P, Trimble MR. A systematic review of the behavioral effects of levetiracetam in adults with epilepsy, cognitive disorders, or an anxiety disorder during clinical trials. Epilepsy Behav . 2003;4(2):124-132. doi:10.1016/s1525-5050(03)00005-2 Verrotti A, Prezioso G, Di Sabatino F, Franco V, Chiarelli F, Zaccara G. The adverse event profile of levetiracetam: A meta-analysis on children and adults. Seizure . 2015;31:49-55. doi:10.1016/j.seizure.2015.07.004 Mukherjee, D., Hapuarachchy, B., Vattipally, V., Horowitz, M., & Kazemi, F. 491 Postoperative Seizure Incidence is Not Affected by Extended Duration of Prophylaxis for Metastatic Brain Tumors. Neurosurgery. 2025; 71. https://doi.org/10.1227/neu.0000000000003360_491 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9543079","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":639816549,"identity":"7da11b41-7a05-4f6f-ae38-03433811c0ce","order_by":0,"name":"Ahmed A. 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1","display":"","copyAsset":false,"role":"figure","size":28061,"visible":true,"origin":"","legend":"\u003cp\u003eBar chart showing the geographic distribution of the participants.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9543079/v1/dc46d75cf6462f04786ad6cc.png"},{"id":109332036,"identity":"98e94d4d-9943-462f-8283-4cef49bfac44","added_by":"auto","created_at":"2026-05-15 16:12:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":32936,"visible":true,"origin":"","legend":"\u003cp\u003ePie chart illustrating the participants’ level of familiarity with the guidelines.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9543079/v1/ffb04947218cc8dd3f537086.png"},{"id":109405556,"identity":"584550db-d6d2-40cc-bbe5-70ec830bd94a","added_by":"auto","created_at":"2026-05-17 13:18:59","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":36834,"visible":true,"origin":"","legend":"\u003cp\u003eBar chat illustrating guideline awareness versus familiarity.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9543079/v1/cba17f9ebff7e11a0f823114.png"},{"id":109405538,"identity":"8b10517a-77e5-4bff-a868-07fdd9a69d78","added_by":"auto","created_at":"2026-05-17 13:18:51","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":22395,"visible":true,"origin":"","legend":"\u003cp\u003ePie chart showing responses to whether the existing guidelines sufficiently address all clinical scenarios.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9543079/v1/4aad555aa119c0a46dd437fe.png"},{"id":109332038,"identity":"cd9d082b-332f-421a-8ab9-898e08ada1c5","added_by":"auto","created_at":"2026-05-15 16:12:53","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":22559,"visible":true,"origin":"","legend":"\u003cp\u003eBar chart showing the clinical areas most frequently perceived as insufficiently addressed.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-9543079/v1/16d8bdf888f90464eca135ed.png"},{"id":109405274,"identity":"9efe0009-46e7-468d-9a73-21334f600bf9","added_by":"auto","created_at":"2026-05-17 13:15:26","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":24859,"visible":true,"origin":"","legend":"\u003cp\u003eBar chart showing AED preferences between the participants.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-9543079/v1/5207c9038d938c58cfb0d4ec.png"},{"id":109405307,"identity":"fb123124-e840-482f-ac57-32960328aae3","added_by":"auto","created_at":"2026-05-17 13:16:30","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":38389,"visible":true,"origin":"","legend":"\u003cp\u003ePie chart showing responses to the question: How frequently do you deviate from clinical guidelines?\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-9543079/v1/af8542c473e688297cc0e9ea.png"},{"id":109405406,"identity":"fda39dc9-e298-46c0-9457-8404134a4303","added_by":"auto","created_at":"2026-05-17 13:17:52","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":51690,"visible":true,"origin":"","legend":"\u003cp\u003eBar chart showing responses to the question: what are reasons for deviation from guidelines?\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-9543079/v1/8a84706140bd9d21d12c3ac0.png"},{"id":109332045,"identity":"cfdb85e9-1f81-4fac-85cb-cbb30d5390d2","added_by":"auto","created_at":"2026-05-15 16:12:53","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":41653,"visible":true,"origin":"","legend":"\u003cp\u003eBar chart showing system barriers to guideline adherence.\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-9543079/v1/088e1baf27fb4d99e33b7907.png"},{"id":109405491,"identity":"192a78e2-1026-4d14-a871-4bb4b9728025","added_by":"auto","created_at":"2026-05-17 13:18:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":495373,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9543079/v1/50217265-6db5-478f-8d26-52d4adb58cae.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Global Variation in Antiepileptic Prophylaxis in Neurosurgery: Assessing Guideline Adherence and Identifying Barriers","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn the neurosurgical population, seizures are a well-recognized complication that may develop following traumatic brain injury (TBI), brain tumors, spontaneous intracranial hemorrhage (ICH), or cranial surgical interventions [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConsequently, antiepileptic drugs (AEDs) are commonly administered to prevent or manage seizures in neurosurgical patients [\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Nonetheless, routine AED prophylaxis in seizure-na\u0026iuml;ve neurosurgical patients lacks strong supporting evidence, and most guidelines recommend it only for high-risk individuals [\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Despite these efforts, Guideline implementation is inconsistent, with substantial variation in AED prescribing. Factors contributing to this include resource availability, adoption of newer AEDs, and dependence on personal clinical experience [\u003cspan additionalcitationids=\"CR25 CR26 CR27 CR28 CR29\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSuch variability in clinical practice may result in inadequate protection for high-risk patients while simultaneously exposing others to unnecessary medication-related adverse effects. [\u003cspan additionalcitationids=\"CR32 CR33 CR34\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e The primary objective of this global survey was to evaluate the current state of AED use among neurosurgeons by assessing: 1) awareness and familiarity with existing guidelines, 2) current prescribing practices across common neurosurgical pathologies, and 3) perceived barriers to guideline adherence.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy Design and Participant Recruitment\u003c/p\u003e \u003cp\u003eA global, cross-sectional online survey targeting neurosurgeons at various professional levels (consultants, associate consultants, registrars, and residents) was performed. The survey was disseminated over a six-month period via social media platforms and direct email. Participation was voluntary and anonymous.\u003c/p\u003e \u003cp\u003eSurvey Development and Data Collection\u003c/p\u003e \u003cp\u003eA 26-item questionnaire was developed using Google Forms\u0026reg;. The survey was structured into four domains:\u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eDemographic and professional background.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e Knowledge and awareness of AED guidelines.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAED prescription practices for neurotrauma, brain tumors, SAH, post-craniotomy, and IPH.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e Adherence to guidelines, perceived barriers, and educational needs.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e \u003cp\u003eThe questionnaire utilized multiple-choice, checklist, and free-text response formats.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eWe summarized data with descriptive statistics (frequencies and percentages) and used chi-square tests to explore associations between categorical variables. (e.g., reasons for guideline deviation by professional role). A P- value of \u0026lt; .05 was considered statistically significant. Qualitative data from open-ended responses were analyzed using inductive thematic analysis by two independent reviewers.\u003c/p\u003e \u003cp\u003eEthical Considerations\u003c/p\u003e \u003cp\u003eThe study protocol received approval from the Institutional Review Board of KAMC. Electronic consent was obtained prior to participation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Demographics and Professional Characteristics (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/h2\u003e \u003cp\u003eAll 310 respondents completed the survey. The cohort was predominantly male (93.5%, n\u0026thinsp;=\u0026thinsp;290). Geographically, most participants were based in the Middle East and North Africa (56.5%, n\u0026thinsp;=\u0026thinsp;175), followed by Asia (17.7%, n\u0026thinsp;=\u0026thinsp;55) and Europe (12.9%, n\u0026thinsp;=\u0026thinsp;40); smaller proportions were from Latin America (7.0%, n\u0026thinsp;=\u0026thinsp;22), North America (4.9%, n\u0026thinsp;=\u0026thinsp;15), and Australia and the Pacific region (1.0%, n\u0026thinsp;=\u0026thinsp;3) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eNearly half of respondents were consultants (46.8%, n\u0026thinsp;=\u0026thinsp;145), followed by registrars (24.2%, n\u0026thinsp;=\u0026thinsp;75), junior residents (17.7%, n\u0026thinsp;=\u0026thinsp;55), and associate consultants (11.3%, n\u0026thinsp;=\u0026thinsp;35). The majority identified as general neurosurgeons (88.7%, n\u0026thinsp;=\u0026thinsp;275). Most participants worked in academic or university hospitals (45.2%, n\u0026thinsp;=\u0026thinsp;140), with others based in public/community hospitals (35.5%, n\u0026thinsp;=\u0026thinsp;110), private practice (16.1%, n\u0026thinsp;=\u0026thinsp;50), and military hospitals (3.2%, n\u0026thinsp;=\u0026thinsp;10). A large proportion reported more than five years of clinical experience (80.6%, n\u0026thinsp;=\u0026thinsp;250).\u003c/p\u003e \u003cp\u003eIn terms of workload, 72.6% (n\u0026thinsp;=\u0026thinsp;225) managed more than 10 inpatient cases per week, while outpatient activity was substantial, with 45.2% (n\u0026thinsp;=\u0026thinsp;140) seeing more than 30 outpatients weekly.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003esummarizing participant demographics and professional characteristics:\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal respondents\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e310\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e290\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRegion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle East \u0026amp; North Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEurope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth America\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLatin America\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralia and Pacific region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePosition / Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRegistrar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJunior resident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAssociate consultant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of neurosurgeon\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther / subspecialty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcademic / University\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic / Community\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMilitary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears of experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInpatient workload\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10 cases/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;10 cases/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOutpatient workload\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30 patients/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30 patients/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Summary of participant demographics and professional characteristics.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eKnowledge and Awareness of Guidelines\u003c/h3\u003e\n\u003cp\u003e Although the majority of neurosurgeons reported being aware of existing antiepileptic drug (AED) guidelines (77.4%, n\u0026thinsp;=\u0026thinsp;240), a notable proportion (22.6%, n\u0026thinsp;=\u0026thinsp;70) indicated a lack of awareness. However, only 30.6% (n\u0026thinsp;=\u0026thinsp;92) considered themselves highly familiar with the guideline content.\u003c/p\u003e \u003cp\u003e The most commonly cited guidelines were those issued by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons (51.6%, n\u0026thinsp;=\u0026thinsp;160), followed by the Brain Trauma Foundation (37.0%, n\u0026thinsp;=\u0026thinsp;115), and the National Institute for Health and Care Excellence (14.5%, n\u0026thinsp;=\u0026thinsp;45). In contrast, smaller groups reported relying on senior colleagues (17.7%, n\u0026thinsp;=\u0026thinsp;55), local institutional protocols (6.5%, n\u0026thinsp;=\u0026thinsp;20), or other national and international society recommendations.\u003c/p\u003e \u003cp\u003eRegarding levels of familiarity (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e), 30.6% (n\u0026thinsp;=\u0026thinsp;92) described themselves as very familiar, 50% (n\u0026thinsp;=\u0026thinsp;155) as somewhat familiar, 16% (n\u0026thinsp;=\u0026thinsp;50) as not familiar, and 3.3% (n\u0026thinsp;=\u0026thinsp;13) stated that they did not follow any guidelines. These findings highlight a discrepancy between general awareness and actual familiarity with guideline content (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOnly one-third of respondents (33.9%, n\u0026thinsp;=\u0026thinsp;105) reported receiving periodic continuing medical education updates or notifications related to these recommendations.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003eWhen questioned about whether existing guidance sufficiently addressed all clinical scenarios, the largest proportion of respondents felt that it did not (38.7%, n\u0026thinsp;=\u0026thinsp;120), while 24.2% (n\u0026thinsp;=\u0026thinsp;75) believed the coverage was adequate and the remainder were uncertain (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003eThe clinical areas most frequently perceived as insufficiently addressed included post-craniotomy management (50.0%, n\u0026thinsp;=\u0026thinsp;155), brain tumours (40.3%, n\u0026thinsp;=\u0026thinsp;125), neurotrauma (38.7%, n\u0026thinsp;=\u0026thinsp;120), and subarachnoid haemorrhage (27.4%, n\u0026thinsp;=\u0026thinsp;85) (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eAED Prescription Practices\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eNeurotrauma\u003c/h2\u003e \u003cp\u003eAmong 310 respondents, AED prophylaxis based on TBI severity was variable. For mild TBI, 9.7% (n\u0026thinsp;=\u0026thinsp;30) prescribed AED, while 45.2% (n\u0026thinsp;=\u0026thinsp;140) did so for moderate TBI, and 48.4% (n\u0026thinsp;=\u0026thinsp;150) for severe TBI according to GCS. Notably, 40.3% (n\u0026thinsp;=\u0026thinsp;125) did not use GCS as a criterion for decision-making. When considering injury location or mechanism, prophylaxis was more frequently applied. Specifically, 33.9% (n\u0026thinsp;=\u0026thinsp;105) prescribed AED for epidural hemorrhages, 71% (n\u0026thinsp;=\u0026thinsp;220) for subdural, 69.4% (n\u0026thinsp;=\u0026thinsp;215) for subarachnoid, 72.6% (n\u0026thinsp;=\u0026thinsp;225) for cerebral intraparenchymal hemorrhages, and 24.2% (n\u0026thinsp;=\u0026thinsp;75) for cerebellar hemorrhages. AED were also prescribed for depressed skull fractures by 56.5% (n\u0026thinsp;=\u0026thinsp;175), diffuse axonal injury by 35.5% (n\u0026thinsp;=\u0026thinsp;110), pneumocephalus by 37% (n\u0026thinsp;=\u0026thinsp;115), brainstem hemorrhage by 8% (n\u0026thinsp;=\u0026thinsp;24), and non-depressed fractures by 4.8% (n\u0026thinsp;=\u0026thinsp;15). Meanwhile, 14.5% (n\u0026thinsp;=\u0026thinsp;45) did not consider injury location in their decisions.\u003c/p\u003e \u003cp\u003ePatient age influenced AED prescription in only 11.3% (n\u0026thinsp;=\u0026thinsp;35) of respondents, whereas 84% (n\u0026thinsp;=\u0026thinsp;260) did not factor age into their decision. In contrast, maternity status had a stronger impact, with 61.3% (n\u0026thinsp;=\u0026thinsp;190) considering pregnancy, childbearing, or breastfeeding status. Regarding prophylaxis duration, 54.8% (n\u0026thinsp;=\u0026thinsp;170) prescribed AED for one week when no posttraumatic seizures were documented. For immediate posttraumatic seizures (\u0026lt;\u0026thinsp;12 hours), 25.8% (n\u0026thinsp;=\u0026thinsp;80) used AED for one week, 43.5% (n\u0026thinsp;=\u0026thinsp;135) for 1\u0026ndash;12 months, and 11.5% (n\u0026thinsp;=\u0026thinsp;35) based duration on EEG findings. For early seizures (\u0026lt;\u0026thinsp;7 days), 21% (n\u0026thinsp;=\u0026thinsp;65) prescribed AED for one week, while late seizures (\u0026gt;\u0026thinsp;7 days) were mainly guided by EEG in 29% (n\u0026thinsp;=\u0026thinsp;90) of respondents, with durations ranging from 3\u0026ndash;6 months 9.7% (n\u0026thinsp;=\u0026thinsp;30), 6\u0026ndash;12 months 22.6% (n\u0026thinsp;=\u0026thinsp;70), and 12\u0026ndash;24 months 17.7% (n\u0026thinsp;=\u0026thinsp;55).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOther Pathologies\u003c/h3\u003e\n\u003cp\u003eFor newly diagnosed, non-operated brain tumors, AED prophylaxis was most commonly prescribed for supratentorial intra-axial tumors (66.1%, n\u0026thinsp;=\u0026thinsp;205) and supratentorial extra-axial tumors (40.3%, n\u0026thinsp;=\u0026thinsp;125), whereas infratentorial tumors were less frequently treated (11.3%, n\u0026thinsp;=\u0026thinsp;35). AED were sometimes used only if epileptic activity developed (40%, n\u0026thinsp;=\u0026thinsp;125) or were not prescribed at all (11.3%, n\u0026thinsp;=\u0026thinsp;35). Intraoperative reloading after mannitol-induced diuresis was reported as \u0026ldquo;yes\u0026rdquo; by 33.9% (n\u0026thinsp;=\u0026thinsp;105), \u0026ldquo;no\u0026rdquo; by 37% (n\u0026thinsp;=\u0026thinsp;115), and \u0026ldquo;sometimes\u0026rdquo; by 33.9% (n\u0026thinsp;=\u0026thinsp;105). The typical postoperative AED duration varied: 16% (n\u0026thinsp;=\u0026thinsp;50) prescribed for 1\u0026ndash;3 months, while others tailored the duration according to surgical extent (8%, n\u0026thinsp;=\u0026thinsp;25), histology (8%, n\u0026thinsp;=\u0026thinsp;25), tumor site (14.5%, n\u0026thinsp;=\u0026thinsp;45), EEG findings (30.6%, n\u0026thinsp;=\u0026thinsp;95), or absence of seizures (29%, n\u0026thinsp;=\u0026thinsp;90).\u003c/p\u003e \u003cp\u003eFor aneurysmal subarachnoid hemorrhage (SAH), prophylactic AED were prescribed selectively in high-risk scenarios, including high Hunt and Hess scale (17.7%, n\u0026thinsp;=\u0026thinsp;55), high WFNS score (8%, n\u0026thinsp;=\u0026thinsp;25), modified Fisher scale\u0026thinsp;\u0026ge;\u0026thinsp;3 (9.7%, n\u0026thinsp;=\u0026thinsp;30), associated hematoma (3.2%, n\u0026thinsp;=\u0026thinsp;10), infarction (42.2%, n\u0026thinsp;=\u0026thinsp;75), sylvian SAH (9.7%, n\u0026thinsp;=\u0026thinsp;30), fluctuating neurological status (12.9%, n\u0026thinsp;=\u0026thinsp;40), or if open surgery was performed (14.5%, n\u0026thinsp;=\u0026thinsp;45). Overall, AED were prescribed in all SAH cases by 53.2% (n\u0026thinsp;=\u0026thinsp;165), while 21% (n\u0026thinsp;=\u0026thinsp;65) never prescribed prophylaxis. The preferred duration ranged from 1 week (14.5%, n\u0026thinsp;=\u0026thinsp;45) to 1 month (11.3%, n\u0026thinsp;=\u0026thinsp;35), 1\u0026ndash;3 months (11.3%, n\u0026thinsp;=\u0026thinsp;35), 3\u0026ndash;6 months (11.3%, n\u0026thinsp;=\u0026thinsp;35), 6\u0026ndash;12 months (4.8%, n\u0026thinsp;=\u0026thinsp;15), EEG-guided (21%, n\u0026thinsp;=\u0026thinsp;65), or never (11.3%, n\u0026thinsp;=\u0026thinsp;35).\u003c/p\u003e \u003cp\u003eIn intraparenchymal hemorrhage (IPH), AED were most commonly prescribed for lobar cortical hemorrhages (66%, n\u0026thinsp;=\u0026thinsp;205) or deep IPH (12.9%, n\u0026thinsp;=\u0026thinsp;40), with cerebellar IPH treated in 4.8% (n\u0026thinsp;=\u0026thinsp;15) and GCS/hematoma-based prescription in 11.3% (n\u0026thinsp;=\u0026thinsp;35). EEG-guided use occurred in 16% (n\u0026thinsp;=\u0026thinsp;50), while 19.4% (n\u0026thinsp;=\u0026thinsp;60) never prescribed AED routinely. Duration ranged from 1 week (16%, n\u0026thinsp;=\u0026thinsp;50) to 1\u0026ndash;3 months (9.7%, n\u0026thinsp;=\u0026thinsp;30), 3\u0026ndash;6 months (12.9%, n\u0026thinsp;=\u0026thinsp;40), 6\u0026ndash;12 months (4.8%, n\u0026thinsp;=\u0026thinsp;15), 12\u0026ndash;24 months (9.7%, n\u0026thinsp;=\u0026thinsp;10), longer durations depending on clinical context (3.2%, n\u0026thinsp;=\u0026thinsp;15), more than 24 months (3.2%, n\u0026thinsp;=\u0026thinsp;10), follow-up EEG (16%, n\u0026thinsp;=\u0026thinsp;50), or occurrence of seizures (27.4%, n\u0026thinsp;=\u0026thinsp;85).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDrug Preference and Monitoring\u003c/p\u003e \u003cp\u003eLevetiracetam was the most commonly prescribed AED (76%, n\u0026thinsp;=\u0026thinsp;235), followed by Phenytoin (19.4%, n\u0026thinsp;=\u0026thinsp;60), while other AED were used less frequently. Regarding adverse events influencing patient compliance, 54.8% (n\u0026thinsp;=\u0026thinsp;170) considered Levetiracetam safest, followed by Phenytoin 21% (n\u0026thinsp;=\u0026thinsp;65) and Valproate 16% (n\u0026thinsp;=\u0026thinsp;50) (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Serum AED levels were routinely monitored by 25.8% (n\u0026thinsp;=\u0026thinsp;80), never monitored by 21% (n\u0026thinsp;=\u0026thinsp;65), sometimes monitored by 32.3% (n\u0026thinsp;=\u0026thinsp;100), and monitored only for specific drugs by 21% (n\u0026thinsp;=\u0026thinsp;65).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAED Withdrawal Practices\u003c/p\u003e \u003cp\u003eA majority of clinicians (84%, n\u0026thinsp;=\u0026thinsp;260) considered AED withdrawal after a patient had been seizure-free for a specified period. Withdrawal was guided by EEG in 61.3% (n\u0026thinsp;=\u0026thinsp;190) or radiological resolution in 21% (n\u0026thinsp;=\u0026thinsp;65), with patient preference influencing 1.6% (n\u0026thinsp;=\u0026thinsp;5). The preferred seizure-free intervals were 3\u0026ndash;6 months (24.2%, n\u0026thinsp;=\u0026thinsp;75), 6\u0026ndash;12 months (25.8%, n\u0026thinsp;=\u0026thinsp;80), 12\u0026ndash;24 months (22.6%, n\u0026thinsp;=\u0026thinsp;70), and 1\u0026ndash;4 weeks (17.7%, n\u0026thinsp;=\u0026thinsp;55). EEG guidance was commonly used by 54.8% (n\u0026thinsp;=\u0026thinsp;170), focusing on normal background activity (24.2%, n\u0026thinsp;=\u0026thinsp;75), absence of epileptiform discharges (67.7%, n\u0026thinsp;=\u0026thinsp;210), and resolution of prior abnormalities (29%, n\u0026thinsp;=\u0026thinsp;90). Limitations to EEG use included unavailability (14.5%, n\u0026thinsp;=\u0026thinsp;45), operator dependence (17.7%, n\u0026thinsp;=\u0026thinsp;55), false negatives (30.6%, n\u0026thinsp;=\u0026thinsp;95), and insufficient evidence (24.2%, n\u0026thinsp;=\u0026thinsp;75). Other factors influencing withdrawal included patient preference (25.8%, n\u0026thinsp;=\u0026thinsp;80), AED side effects (54.8%, n\u0026thinsp;=\u0026thinsp;170), prior cranial surgery (27.4%, n\u0026thinsp;=\u0026thinsp;85), persistent brain pathology (27.4%, n\u0026thinsp;=\u0026thinsp;85), patient occupation (19.4%, n\u0026thinsp;=\u0026thinsp;60), and injury site (43.5%, n\u0026thinsp;=\u0026thinsp;135).\u003c/p\u003e\n\u003ch3\u003eAdherence to Guidelines and Perceived Barriers\u003c/h3\u003e\n\u003cp\u003e Deviation from clinical guidelines for AED use was common. Over half of respondents reported sometimes departing from recommendations (51.6%, n\u0026thinsp;=\u0026thinsp;160), while 16.0% (n\u0026thinsp;=\u0026thinsp;50) reported often deviating. In contrast, 22.6% (n\u0026thinsp;=\u0026thinsp;70) indicated that they rarely deviated, 6.4% (n\u0026thinsp;=\u0026thinsp;20) reported always deviating, and only 3.3% (n\u0026thinsp;=\u0026thinsp;10) stated that they never departed from guideline recommendations (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e7\u003c/span\u003e). Consultants were significantly more likely than trainees to deviate on the basis of personal clinical experience (52.2% vs 29.4%; P = .042).\u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003eThe most commonly cited reasons for deviation were patient-specific clinical factors (48.4%, n\u0026thinsp;=\u0026thinsp;150) and reliance on personal clinical experience (43.5%, n\u0026thinsp;=\u0026thinsp;135). Additional contributing factors included the presence of multiple or conflicting guidelines (38.7%, n\u0026thinsp;=\u0026thinsp;120), lack of familiarity with recommendations (25.8%, n\u0026thinsp;=\u0026thinsp;80), limited supporting evidence (24.2%, n\u0026thinsp;=\u0026thinsp;75), institutional resource constraints (22.6%, n\u0026thinsp;=\u0026thinsp;70), and concerns regarding adverse effects (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e From a systems perspective, the main barriers to effective guideline implementation were AED availability and cost (30.6%, n\u0026thinsp;=\u0026thinsp;95) and patient non-compliance (14.5%, n\u0026thinsp;=\u0026thinsp;45) (Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eInterdisciplinary Collaboration and Educational Needs\u003c/h2\u003e \u003cp\u003eThe degree of neurology involvement in AED prescribing varied among respondents. Only 6.6% (n\u0026thinsp;=\u0026thinsp;20) reported always consulting neurology, while 27.4% (n\u0026thinsp;=\u0026thinsp;85) consulted very often, 37% (n\u0026thinsp;=\u0026thinsp;115) sometimes, and 29% (n\u0026thinsp;=\u0026thinsp;90) rarely.\u003c/p\u003e \u003cp\u003eWhen consultation was discretionary, neurologists were most frequently involved for patients with pre-existing epilepsy (51.6%, n\u0026thinsp;=\u0026thinsp;160), refractory seizures (82.3%, n\u0026thinsp;=\u0026thinsp;255), AED-related adverse effects (51.6%, n\u0026thinsp;=\u0026thinsp;160), long-term AED therapy (35.5%, n\u0026thinsp;=\u0026thinsp;110), or during AED weaning plans (38.7%, n\u0026thinsp;=\u0026thinsp;120). A minority of respondents (6.5%, n\u0026thinsp;=\u0026thinsp;20) reported never consulting neurology.\u003c/p\u003e \u003cp\u003eAlmost all participants (98.4%, n\u0026thinsp;=\u0026thinsp;305) expressed a desire for additional education and training on optimal AED use. Online webinars were the preferred learning modality (66%, n\u0026thinsp;=\u0026thinsp;205), followed by concise guideline summaries (50%, n\u0026thinsp;=\u0026thinsp;155). Some respondents also recommended self-directed online modules, regular email updates summarising key recommendations or featuring case-based discussions, and the development of a mobile application to assist with AED prescribing as strategies to improve awareness of, and adherence to, clinical guidelines.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur findings reveal continued variation and uncertainty in AED prophylaxis practices among neurosurgeons, reflecting trends reported in previous multicenter studies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. These findings suggest that heterogeneity in prescribing practices remains a global issue despite the availability of guideline-based recommendations.\u003c/p\u003e \u003cp\u003eWhile participants were from several continents, the sample was weighted toward the MENA region, limiting global representativeness. Therefore, the findings should be interpreted as reflecting broad international input rather than strictly global representativeness.\u003c/p\u003e \u003cp\u003eThe substantial contribution from the MENA offers insight into a neurosurgical community that has historically been underrepresented in survey-based research. In addition, responses were collected from multiple continents and diverse practice environments, enhancing the international scope of the dataset.\u003c/p\u003e \u003cp\u003eImportantly, to our knowledge, this is among the first surveys to comprehensively evaluate antiepileptic prescribing practices across the full spectrum of neurosurgical conditions rather than focusing on a single pathology.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eEvidence Base and Recommendations\u003c/h2\u003e \u003cp\u003eContemporary systematic reviews and major professional society guidelines generally discourage routine prophylactic AED administration in seizure-na\u0026iuml;ve patients with conditions such as SAH, ICH, TBI, or newly diagnosed brain tumors, except in selected high-risk circumstances [\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe SNO/EANO and AAN guidelines specifically advise against routine prophylaxis, emphasizing that decisions should not be based on tumor location, histology, or molecular features due to a lack of predictive value [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Similarly, for traumatic brain injury and other neurosurgical pathologies, the evidence supporting routine prophylactic AED is equivocal, and clinical judgment remains paramount [\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18 CR19\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePersistent Practice Variation and Guideline Gaps\u003c/h2\u003e \u003cp\u003e Despite existing guidelines, considerable uncertainty remains about the timing, choice of agents, and duration of AED prophylaxis. Several surveys have assessed antiepileptic prescribing patterns in brain-tumour surgery over the past two decades; however, their use in other neurosurgical conditions has not been explored, likely because guidelines in those areas are viewed as more established compared with brain-tumour surgery [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, 66.1% of neurosurgeons prescribed AED prophylactically for newly diagnosed supratentorial intra-axial tumors without prior seizures, closely mirroring the 63% who \"always or almost always\" prescribed prophylaxis in the AANS/CNS survey. This consistency across different study populations and time periods underscores the persistent nature of this clinical dilemma, even a decade later [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA 2005 survey from the United States by Siomin et al. reported that 70% of neurosurgeons routinely used AED prophylaxis after craniotomy, with the highest use in intra-axial tumors [26). In contrast, data from the United Kingdom showed far lower adoption, as 59% of surgeons never prescribed AED for glioma surgery and 79% avoided them in meningioma resections [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMore recently, a U.S. pharmacy-claims analysis demonstrated that 40.7% of patients undergoing brain-tumor resection or biopsy received postoperative AED prophylaxis. Usage was highest in open supratentorial intraparenchymal tumor resections (62.5%) and much lower for infratentorial cases (9.7%). Levetiracetam was the predominant agent (78.5%), followed by phenytoin (20.5%) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA recent Italian survey examined postoperative AED practices among neurosurgeons, gathering responses from 82 clinicians representing half of the country\u0026rsquo;s neurosurgical units. More than half reported routinely prescribing AED to seizure-free patients, with supratentorial tumor location being the main determinant. Levetiracetam was used almost universally (97.7%), and 23.8% maintained therapy for more than six months. After early postoperative seizures, nearly all participants (96.3%) initiated treatment. Only 4 surgeons (5.1%) routinely stopped AED within one month, whereas 32 (40.5%) extended therapy beyond six months. Remarkably, fewer than half (48.7%) involved a neurologist in managing AED decisions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTaken together, when aggregating data from the previously published surveys summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, approximately 80% of clinicians\u0026mdash;practicing across diverse regions worldwide\u0026mdash;reported routinely prescribing postoperative antiepileptic medications following tumor resection.\u003c/p\u003e \u003cp\u003eBeyond brain tumors, our survey captured practice patterns in neurotrauma, ICH, and SAH\u0026mdash;areas where the evidence base is considered more established\u0026mdash;and still demonstrated marked variability in both indications and duration of prophylaxis. This variation suggests that even in areas with clearer guidelines, adherence is not universal.\u003c/p\u003e \u003cp\u003eLevetiracetam has consistently been reported as the first-line AED across recent surveys (75.8% in our cohort, compared with 85% in Dewan et al. and 97.7% in Pascarella et al.). This trend marks a notable shift from earlier surveys, in which phenytoin predominated [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The comparatively lower rate observed in our study may reflect the fact that most respondents practice in North Africa and the Middle East, where resource limitations can influence AED selection.\u003c/p\u003e \u003cp\u003eAcross all studies\u0026mdash;including our own\u0026mdash;clinicians frequently continue prophylactic AED beyond two weeks [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Prolonged AED administration continues, even though evidence for its effectiveness in preventing late seizures or improving outcomes remains limited [\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan additionalcitationids=\"CR43\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Moreover, collective literature consistently highlights the absence of consensus on optimal treatment duration in many clinical scenarios, a critical knowledge gap that directly impacts patient care [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eprovides a summary of surveys evaluating prophylactic AED use in neurosurgery.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthors \u0026amp; Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTarget Specialty, (No. of Responders), location of practice\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003espectrum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrescribing Frequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrimary Agent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDuration of AED Administration\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBrouwers et al., 2003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical oncology, neurology, radiation oncology, neurosurgery (122), practicing in Ontario, Canada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBrain tumour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAlways (22%), Sometimes (48%), Never (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnspecified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnspecified\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSiomin et al., 2005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral neurosurgery, members of AANS (386), location of practice not specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBrain tumour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRoutinely\u0026thinsp;\u0026gt;\u0026thinsp;70%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePhenytoin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e~\u0026thinsp;1 week (18%), 2\u0026ndash;6 weeks (35%), \u0026gt;\u0026thinsp;6 weeks (36%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDewan et al., 2016\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeurosurgery, oncology, AANS/CNS tumour section members (133), practicing in 16 countries, and 5 continents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBrain tumour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAlways (63%), Sometimes (9%), Never (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLevetiracetam (85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e~\u0026thinsp;1 week (25%), 2\u0026ndash;6 weeks (37%), \u0026gt;\u0026thinsp;6 weeks (13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePascarella et al., 2023\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdult and pediatric neurosurgeons (82), practicing in Italy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBrain tumour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.1% routinely prescribe AED post-craniotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLevetiracetam (97.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.8% continue\u0026thinsp;\u0026gt;\u0026thinsp;6 months; after early seizures: 40.5% continue\u0026thinsp;\u0026gt;\u0026thinsp;6 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent Global Survey, 2025\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeurosurgeons (310), practicing worldwide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBrain tumour TBI, ICH, SAH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVaried widely according to pathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLevetiracetam (75.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eVaried widely according to pathology\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Summary of surveys evaluating prophylactic antiepileptic drug (AED) use in neurosurgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to Guideline Adherence\u003c/h2\u003e \u003cp\u003eOur findings, in line with quality improvement studies, suggest that the major barriers to guideline adherence include lack of awareness, perceived guideline complexity, patient-specific factors and reliance on personal or institutional experience [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe significant finding that consultants more frequently rely on personal experience suggests that as neurosurgeons mature, they may develop their own practice patterns that supersede published recommendations. This is compounded by the infrequent collaboration with neurologists, potentially limiting exposure to specialized epilepsy management expertise. The reliance on senior colleagues and local institutional guidelines as primary sources, as reported by our respondents, further underscores this culture of experiential learning over strict guideline adherence.\u003c/p\u003e \u003cp\u003eImportantly, although prophylactic AED are routinely prescribed by most surgeons in both our survey and prior studies, significant uncertainty remains regarding their true effectiveness. In the AANS/CNS survey, 62% of participants either doubted or were unsure whether prophylactic AED actually reduced postoperative seizures [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], highlighting the same evidence-practice gap we observed, where clinicians often rely on personal experience rather than guideline recommendations. This issue is especially pertinent for brain tumor patients, as the AAN and CNS guideline advises against routine prophylaxis [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], a recommendation that continues to generate debate. The persistently high rates of prophylaxis reported in our survey and previous studies\u0026mdash;despite skepticism and guideline advice\u0026mdash;suggest a combination of defensive medicine and a deeply entrenched institutional culture that remain difficult to change.\u003c/p\u003e \u003cp\u003e Our respondents also indicated that tools such as online webinars, self-paced digital courses, periodic emails summarizing guidelines or presenting case-based discussions, and a mobile application to support AED prescribing could enhance guideline awareness and adherence. Such initiatives could contribute to reducing unwarranted AED prescribing, lowering costs, minimizing treatment-related adverse effects, and ultimately enhancing overall patient quality of life.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eAgent Selection and Adverse Effects\u003c/h2\u003e \u003cp\u003eLevetiracetam has emerged as the preferred agent because of its favorable side-effect profile and minimal drug interactions, particularly when compared with older AED such as phenytoin [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], factors that may contribute to its widespread\u0026mdash;and potentially excessive\u0026mdash;use among neurosurgeons.\u003c/p\u003e \u003cp\u003eNevertheless, Levetiracetam is associated with psychiatric and behavioral adverse effects in approximately 10\u0026ndash;25% of patients (e.g., irritability, agitation, aggression, emotional lability, depression), with severe manifestations such as psychosis or suicidality occurring in about 1\u0026ndash;2% of cases [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Symptoms typically emerge within the first 2\u0026ndash;6 weeks of treatment or following rapid dose escalation [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRisk factors include pre-existing psychiatric disorders (e.g., depression, anxiety), female sex, recreational drug use, polytherapy, and rapid titration [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. These factors should be evaluated prior to initiating Levetiracetam to determine the risk of psychiatric complications, which might warrant selecting an alternative antiepileptic drug.\u003c/p\u003e \u003cp\u003eAlthough most psychiatric adverse effects are reversible, this does not justify unnecessary or prolonged prescription. Extended or inappropriate use increases treatment costs, medication burden, and the risk of additional adverse effects without improving clinical outcomes [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eNeed for Further Research and Unified Guidelines\u003c/h2\u003e \u003cp\u003eThe absence of robust, large-scale randomized controlled trials continues to hinder the development of clear, evidence-based practice standards [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. This underscores the pressing need for multicenter studies to better define the effectiveness of seizure prophylaxis and guide future recommendations. In the meantime, care must rely on a multidisciplinary, patient-focused strategy that integrates existing evidence with clinical expertise and individual patient preferences.\u003c/p\u003e \u003cp\u003eThe overwhelming demand for enhanced education (98.4% in our survey) and the request for streamlined protocols signal a strong directive for the neurosurgical field. Collaborative efforts between neurology and neurosurgery societies could be instrumental in meeting this need by increasing awareness, developing evidence-based practice standards, and promoting joint strategies aimed at reducing the routine use of AED.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eFuture perspective\u003c/h2\u003e \u003cp\u003eFurther investigations incorporating prescribing audits and linkage to patient outcomes are warranted to determine the clinical impact of observed practice variation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStudy Limitations\u003c/h2\u003e \u003cp\u003eThe results of this study should be interpreted in light of several limitations. A probability-based sampling approach was not achievable, and although the total number of respondents is comparable to or larger than many single-centre surveys, the predominance of participants from MENA region may limit the generalizability of the findings to truly global neurosurgical practice. Nevertheless, the substantial representation from the MENA region offers important perspectives from a neurosurgical community that has been relatively underrepresented in previous survey-based studies.\u003c/p\u003e \u003cp\u003eAs with all clinician-administered surveys, responses reflect reported rather than independently audited practice patterns. The voluntary nature of participation introduces potential self-selection bias, as neurosurgeons with stronger interest in seizure prophylaxis may have been more likely to respond.\u003c/p\u003e \u003cp\u003eAlthough the questionnaire was informed by existing literature and underwent expert review to support content validity, it remains subject to the inherent constraints of clinician-administered survey instruments.\u003c/p\u003e \u003cp\u003eDespite these limitations, participation across multiple continents and practice environments provides a broad perspective on contemporary neurosurgical attitudes toward seizure prophylaxis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis international survey highlights a considerable opportunity to improve the quality of care for neurosurgical patients. Narrowing the gap between evidence and clinical practice necessitates a focused effort to create clear, consensus-based guidelines and implement them via targeted, accessible educational strategies appreciated by both trainees and experienced surgeons. The recurring patterns observed across multiple surveys underscore that this variability in practice constitutes a core challenge in neurosurgical care, calling for coordinated solutions through high-quality clinical trials and more effective guideline dissemination.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAAN\u003c/strong\u003e \u0026ndash; American Academy of Neurology\u003cbr\u003e\u003cstrong\u003eAANS\u003c/strong\u003e \u0026ndash; American Association of Neurological Surgeons\u003cbr\u003e\u003cstrong\u003eAED\u003c/strong\u003e \u0026ndash; Antiepileptic Drug\u003cbr\u003e\u003cstrong\u003eBTF\u003c/strong\u003e \u0026ndash; Brain Trauma Foundation\u003cbr\u003e\u003cstrong\u003eCNS\u003c/strong\u003e \u0026ndash; Congress of Neurological Surgeons\u003cbr\u003e\u003cstrong\u003eEANO\u003c/strong\u003e \u0026ndash; European Association of Neuro-Oncology\u003cbr\u003e\u003cstrong\u003eEEG\u003c/strong\u003e \u0026ndash; Electroencephalogram\u003cbr\u003e\u003cstrong\u003eGCS\u003c/strong\u003e \u0026ndash; Glasgow Coma Scale\u003cbr\u003e\u003cstrong\u003eICH\u003c/strong\u003e \u0026ndash; Intracerebral Haemorrhage / Intracranial Haemorrhage\u003cbr\u003e\u003cstrong\u003eIPH\u003c/strong\u003e \u0026ndash; Intraparenchymal Haemorrhage\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKAMC\u003c/strong\u003e \u0026ndash; King Abdullah Medical City\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMENA\u0026nbsp;\u003c/strong\u003e\u0026ndash; Middle East and North Africa\u003cbr\u003e\u003cstrong\u003eNCS\u003c/strong\u003e \u0026ndash; Neurocritical Care Society\u003cbr\u003e\u003cstrong\u003eSAH\u003c/strong\u003e \u0026ndash; Subarachnoid Haemorrhage\u003cbr\u003e\u003cstrong\u003eSNO\u003c/strong\u003e \u0026ndash; Society for Neuro-Oncology\u003cbr\u003e\u003cstrong\u003eTBI\u003c/strong\u003e \u0026ndash; Traumatic Brain Injury\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDAI\u003c/strong\u003e \u0026ndash; Diffuse Axonal Injury\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to restrictions on data sharing but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe authors thank all the neurosurgeons who participated in this survey.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or non-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAhmed A. Farag: Conceptualization, Methodology, Investigation, Data curation, Formal analysis, Project administration, Writing \u0026ndash; original draft.\u003c/p\u003e\n\u003cp\u003eWaeel O. Hamouda: Conceptualization, Methodology, Supervision, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eRamez W. Kirollos: Methodology, Validation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eSameh E. Hassan: Investigation, Data curation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eHussein Kheshaifati: Investigation, Data curation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eMohammad G. Abdoh: Investigation, Data curation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eSultan Al-Saiari: Supervision, Validation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eMubasher A. Mir: Methodology, Validation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eEssam M. Rezk: Supervision, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eYoseri J. Alhamss: Investigation, Data curation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eAbdelmoneim A. Kamar: Investigation, Data curation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eAbdulrahman A. Alshamrani: Investigation, Data curation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eFaisal A. Sukkar: Investigation, Data curation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eAlaaeldein Nagy: Data curation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eMohamed M. Ismail: Data curation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eMuhamad F. Thamrin: Data curation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eAbdelazim L. Sadaka: Investigation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eMohamed Okasha: Validation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eMohamed A. Khoudir: Validation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eYahya M. Mir: Investigation, Data curation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eWaleed M. Alzahrani: Validation, Clinical input, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eAsmaa A. Abdelaziz: Data curation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eKhalid Al-Orabi: Conceptualization, Supervision, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSconzo, D., Wadhwa, A., Balagurunath, K., Berube, M., Enriquez-Marulanda, A., Wetsel, Z., Ravina, K., \u0026amp; Binello, E. 1259\u0026emsp;Predictors of Seizures in Patients Post Op From Surgical Intervention for Traumatic Brain Injury. \u003cem\u003eNeurosurgery.\u003c/em\u003e 2025; 71. https://doi.org/10.1227/neu.0000000000003360_1259.\u003c/li\u003e\n \u003cli\u003eImsamer, A., Sitthinamsuwan, B., Tansirisithikul, C., \u0026amp; Nunta-Aree, S. 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J Neurol Neurosurg Psychiatry 2019;90(5):599\u0026ndash;607. https://doi.org/10.1136/jnnp-2018-319609.\u003c/li\u003e\n \u003cli\u003eTanti MJ, Marson AG, Jenkinson MD. Epilepsy and adverse quality of life in surgically resected meningioma. Acta Neurol Scand 2017;136(3):246\u0026ndash;53. https:// doi.org/10.1111/ane.12711.\u003c/li\u003e\n \u003cli\u003eJosephson CB, Engbers JDT, Jette N, et al. Prediction Tools for Psychiatric Adverse Effects After Levetiracetam Prescription. \u003cem\u003eJAMA Neurol\u003c/em\u003e. 2019;76(4):440-446. doi:10.1001/jamaneurol.2018.4561.\u003c/li\u003e\n \u003cli\u003ePerucca, P., \u0026amp; Gilliam, F. Adverse effects of antiepileptic drugs. \u003cem\u003eThe Lancet Neurology.\u003c/em\u003e 2012; 11. https://doi.org/10.1016/s1474-4422(12)70153-9.\u003c/li\u003e\n \u003cli\u003eLee, S., Sung, D., Cho, E., Min, J., Shin, S., \u0026amp; Choi, Y. Investigation into Safety Profiles of Antiepileptic Drugs and Identification of Predictors for Serious Adverse Events: Insights from National Pharmacovigilance Data. \u003cem\u003ePharmaceuticals.\u003c/em\u003e 2025; 18. https://doi.org/10.3390/ph18071013.\u003c/li\u003e\n \u003cli\u003eDewan MC, White-Dzuro GA, Brinson PR, Thompson RC, Chambless LB. Perioperative seizure in patients with glioma is associated with longer hospitalization, higher readmission, and decreased overall survival. J Neurosurg 2016;125(4):1033\u0026ndash;41. https://doi.org/10.3171/2015.10.JNS151956.\u003c/li\u003e\n \u003cli\u003eChandra, V., Rock, A., Opalak, C., Stary, J., Sima, A., Carr, M., Vega, R., \u0026amp; Broaddus, W. A systematic review of perioperative seizure prophylaxis during brain tumor resection: the case for a multicenter randomized clinical trial.. \u003cem\u003eNeurosurgical focus.\u003c/em\u003e 2017; 43 5. https://doi.org/10.3171/2017.8.focus17442\u003c/li\u003e\n \u003cli\u003eJiang, M., Xu, Y., Yang, L., Yan, Y., Zhou, H., Song, W., Wang, X., Sun, H., Yao, X., Zhao, Z., \u0026amp; Li, C. Evidence-based recommendations for the prophylactic use of antiseizure medications (ASMs) in neurosurgery: a systematic review of guidelines. \u003cem\u003eJournal of neurology.\u003c/em\u003e 2024; 272 1. https://doi.org/10.1007/s00415-024-12764-9.\u003c/li\u003e\n \u003cli\u003eGlantz MJ, Cole BF, Forsyth PA, et al. Practice parameter: anticonvulsant prophylaxis in patients with newly diagnosed brain tumors [RETIRED]. Report of the Quality Standards Subcommittee of the American Academy of Neurology. \u003cem\u003eNeurology\u003c/em\u003e. 2000;54(10):1886-1893. doi:10.1212/wnl.54.10.1886.\u003c/li\u003e\n \u003cli\u003eMee, H., Kolias, A., Chari, A., Ercole, A., Lecky, F., Turner, C., Tudur-Smith, C., Coles, J., Anwar, F., Belli, A., Manford, M., Ham, T., McMahon, C., Bulters, D., Uff, C., Duncan, J., Wilson, M., Marson, A., \u0026amp; Hutchinson, P. Pharmacological management of post-traumatic seizures in adults: current practice patterns in the UK and the Republic of Ireland. \u003cem\u003eActa Neurochirurgica.\u003c/em\u003e 2018; 161. https://doi.org/10.1007/s00701-018-3683-9\u003c/li\u003e\n \u003cli\u003eUribe, A., Zuleta-Alarc\u0026oacute;n, A., Kassem, M., Sandhu, G., \u0026amp; Bergese, S. Intraoperative Seizures: Anesthetic and Antiepileptic Drugs.. \u003cem\u003eCurrent pharmaceutical design.\u003c/em\u003e 2018; 23 42. https://doi.org/10.2174/1381612823666171024154026.\u003c/li\u003e\n \u003cli\u003eTurnbull, D., Singatullina, N., \u0026amp; Reilly, C. A Systematic Appraisal of Neurosurgical Seizure Prophylaxis: Guidance for Critical Care Management. \u003cem\u003eJournal of Neurosurgical Anesthesiology.\u003c/em\u003e 2015; 28. https://doi.org/10.1097/ana.0000000000000206.\u003c/li\u003e\n \u003cli\u003eJenkinson MD, Ali A, Islim AI, Helmy A, Grant R. Letter to the Editor. Establishing the role of prophylactic antiepileptic drugs in glioma and meningioma surgery. J Neurosurg 2019;131(3):985\u0026ndash;7. https://doi.org/10.3171/2019.\u003c/li\u003e\n \u003cli\u003eWang YC, Chuang CC, Tu PH, Wei KC, Wu CT, Lee CC, et al. Seizures in surgically resected atypical and malignant meningiomas: long-term outcome analysis. 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Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Prophylactic Anticonvulsants in the Treatment of Adults with Metastatic Brain Tumors. \u003cem\u003eNeurosurgery\u003c/em\u003e. 2019;84(3):E195-E197. doi:10.1093/neuros/nyy545.\u003c/li\u003e\n \u003cli\u003eLee CH, Koo HW, Han SR, Choi CY, Sohn MJ, Lee CH. Phenytoin versus levetiracetam as prophylaxis for postcraniotomy seizure in patients with no history of seizures: systematic review and meta-analysis. J Neurosurg 2019;130(6): 2063\u0026ndash;70. https://doi.org/10.3171/2018.4.JNS1891.\u003c/li\u003e\n \u003cli\u003eCramer JA, De Rue K, Devinsky O, Edrich P, Trimble MR. A systematic review of the behavioral effects of levetiracetam in adults with epilepsy, cognitive disorders, or an anxiety disorder during clinical trials. \u003cem\u003eEpilepsy Behav\u003c/em\u003e. 2003;4(2):124-132. doi:10.1016/s1525-5050(03)00005-2\u003c/li\u003e\n \u003cli\u003eVerrotti A, Prezioso G, Di Sabatino F, Franco V, Chiarelli F, Zaccara G. The adverse event profile of levetiracetam: A meta-analysis on children and adults. \u003cem\u003eSeizure\u003c/em\u003e. 2015;31:49-55. doi:10.1016/j.seizure.2015.07.004\u003c/li\u003e\n \u003cli\u003eMukherjee, D., Hapuarachchy, B., Vattipally, V., Horowitz, M., \u0026amp; Kazemi, F. 491\u0026emsp;Postoperative Seizure Incidence is Not Affected by Extended Duration of Prophylaxis for Metastatic Brain Tumors. \u003cem\u003eNeurosurgery.\u003c/em\u003e 2025; 71. https://doi.org/10.1227/neu.0000000000003360_491\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Antiepileptic drugs, Seizure prophylaxis, Traumatic brain injury, Brain neoplasms, Intracranial hemorrhage","lastPublishedDoi":"10.21203/rs.3.rs-9543079/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9543079/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective:\u003c/h2\u003e \u003cp\u003e Although guidelines exist for prophylactic antiepileptic drug (AED) use in neurosurgery, their application in clinical practice varies, and adherence among practitioners is not well-characterized. This study aimed to evaluate global neurosurgical practices regarding AED prescribing, assess guideline awareness and adherence, and identify barriers contributing to practice variation.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA 26-item, cross-sectional, web-based survey was distributed internationally to practising neurosurgeons. The questionnaire assessed demographic characteristics, familiarity with established guidelines, prescribing patterns across major neurosurgical pathologies (traumatic brain injury, brain tumours, subarachnoid haemorrhage, intraparenchymal haemorrhage, and post-craniotomy states), and perceived obstacles to guideline implementation. Descriptive statistics and chi-square analyses were performed to evaluate associations between professional characteristics and prescribing behaviour.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eA total of 310 neurosurgeons from multiple continents completed the survey. Although 77.4% reported awareness of existing AED guidelines, only 30.6% considered themselves highly familiar with their content. Levetiracetam was the most frequently prescribed AED (76%), yet prophylactic prescribing patterns differed substantially among the surveyed pathologies, including conditions where routine prophylaxis is not recommended. Guideline deviation was common: 51.6% reported, sometimes departing from recommendations, primarily due to patient-specific factors (48.4%) and reliance on personal clinical experience (43.5%). Consultants were significantly more likely than trainees to deviate based on experiential judgment (P = .042). Two-thirds of respondents perceived current recommendations as insufficient, and 98.4% expressed a need for enhanced educational support.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eA substantial evidence\u0026ndash;practice gap persists in the prophylactic use of AED in neurosurgery. Awareness of guidelines does not reliably translate into adherence, and prescribing decisions are frequently influenced by experiential and contextual factors. The findings underscore the need for clearer, harmonised, and accessible recommendations supported by targeted educational strategies to reduce unwarranted variability and optimise patient outcomes.\u003c/p\u003e","manuscriptTitle":"Global Variation in Antiepileptic Prophylaxis in Neurosurgery: Assessing Guideline Adherence and Identifying Barriers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-15 16:12:48","doi":"10.21203/rs.3.rs-9543079/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"877038ba-876d-4724-8288-2c0c5f55da6d","owner":[],"postedDate":"May 15th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"315609242975731238631048630277277185235","date":"2026-05-13T14:45:19+00:00","index":57,"fulltext":""},{"type":"reviewerAgreed","content":"305159231767404652155943994087847218735","date":"2026-05-11T10:25:30+00:00","index":56,"fulltext":""},{"type":"reviewersInvited","content":"50","date":"2026-05-06T07:36:19+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T16:12:48+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-15 16:12:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9543079","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9543079","identity":"rs-9543079","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}