When the practice does not meet the evidence: An Italian survey on the use of antiseizure medications in routine neurosurgery practice

Purpose: Anti-seizure medications (ASMs) to prevent seizures after craniotomy are not currently recommended. This survey investigates practice patterns and decision-making strategies regarding post-craniotomy ASM prophylaxis among Italian neurosurgeons. Methods: An online cross-sectional survey was conducted (November 2022-March 2023). The survey link was distributed to neurosurgeons working in Italian Pediatric and Adult Neurosurgery Units. The survey consisted of ten multiple-choice questions covering ASM prescription for individuals without seizures and those experiencing early post-surgical seizures, including type and timing of ASMs, decision factors, and withdrawal management. Results: Eighty-two neurosurgeons from 64/128 (50 %) Neurosurgery Units completed the questionnaire. Forty-two (52.1 %) neurosurgeons reported routinely prescribing ASMs post-craniotomy for seizure-free individuals. The surgical site, particularly supratentorial locations, emerged as a relevant factor influencing the decision. Levetiracetam (LEV) was the most prescribed ASM (41/42; 97.6 %), with 23.8 % of neurosurgeons maintaining it beyond six months. After early post-surgical seizures, almost all surgeons (96.3 %) prescribed ASMs, primarily LEV (77/79; 97.5 %). Only 4 (5.1 %) surgeons routinely discontinued ASMs within one month, while 32 (40.5 %) continued treatment beyond six months. Notably, only 39 (48.7 %) sought neurologist assistance for ASM management. Conclusion: This survey reveals widespread ASM use (especially LEV) after craniotomy in routine neurosurgery practice in Italy, even in cases where their indication is not supported by existing evidence. These findings emphasize the need to promote the widespread dissemination of standardized, evidence-based recommendations to better align clinical practices with scientific evidence, ultimately improving patient care.