[Practical Guide to Antiseizure Medication Management]

Perioperative seizure management is an important component of neurosurgical care. Antiseizure medications (ASMs) have historically been used prophylactically in many neurosurgical patients; however, current evidence does not support routine prophylaxis in seizure-naïve individuals. Recent guidelines recommend ASM administration primarily for patients with a history of seizures or for short-term use during the immediate perioperative period in selected high-risk conditions. Accordingly, prophylactic treatment should be individualized based on seizure risk and generally limited to short-term use to avoid unnecessary long-term exposure. This review summarizes three clinically relevant areas. First, we summarize evidence-based strategies for perioperative seizure prophylaxis in major neurosurgical conditions, including brain tumors, traumatic brain injury, and cerebrovascular disease. Second, we review the pharmacological properties of newer ASMs commonly used in neurosurgical practice, including levetiracetam, lacosamide, brivaracetam, and perampanel, with emphasis on their mechanisms of action, adverse-effect profiles, and practical advantages in perioperative settings, such as the availability of intravenous formulations. Finally, we discuss the clinical applications of long-term video electroencephalographic monitoring (VEEG), including evaluation for epilepsy surgery, detection of nonconvulsive status epilepticus, and differential diagnosis of seizure-like events such as syncope and functional/dissociative seizures. Risk-based ASM management combined with appropriate utilization of VEEG is essential for optimizing perioperative neurological care.