The management of brain metastases (BM) in geriatric patients poses significant challenges in the context of an aging population and advances in systemic cancer treatment. This study provides insights into the prevalence and nature of adverse events (AEs) following intracranial surgery in patients aged 65 years and older. It highlights the complexities and implications of treating this demographic patient population and identifies risk factors associated with AEs. This prospective study includes patients aged 65 years and older with BM who underwent surgery between January 2022 and December 2023. A detailed assessment of AEs, defined as any complication occurring within the first 30 days post-surgery, was conducted. Potential risk factors for the occurrence of AEs were examined. The study encompassed 104 patients, averaging 70.1 ± 2.8 years, with 102 undergoing surgery. The mean age-adjusted Charlson Comorbidity Index (CCI) score was 8.9 ± 1.2, indicating a significant comorbidity burden, predominantly cardiac conditions. The Karnofsky Performance Scale (KPS) showed substantial improvement post-surgery, increasing from 71.3% ± 7.8 to 75.1% ± 5.0 (p = 0.045). The average hospital stay was 10.6 days. Four non-surgery-related mortalities occurred within the 30-day postoperative period. Surgery-related AEs included wound complications in two patients, with one necessitating surgical revision. Advanced age and comorbidities emerged as significant predictors of AEs. Our findings suggest that neurosurgical intervention for BM in the elderly is a feasible and safe option, demonstrating favorable morbidity and mortality rates. However, careful postoperative monitoring is crucial, especially considering the baseline health status of these patients, which increases their susceptibility to AEs. Standardizing protocols for AE reporting and analysis is essential for improving clinical outcomes and maintaining the quality of healthcare for this patient population.