Management of brain tumour related epilepsy (BTRE): a narrative review and therapy recommendations

Abstract

Brain Tumour Related Epilepsy (BTRE) has a significant impact on Quality of Life with implications for driving, employment, and social activities. Management of BTRE is complex due to the higher incidence of drug resistance and the potential for interaction between anti-cancer therapy and anti-seizure medications (ASMs). Neurologists, neurosurgeons, oncologists, palliative care physicians and clinical nurse specialists treating these patients would benefit from up-to-date clinical guidelines. We aim to review the current literature and to outline specific recommendations for the optimal treatment of BTRE, encompassing both Primary Brain Tumours (PBT) and Brain Metastases (BM). A comprehensive search of the literature since 2000 on BTRE was carried out in PubMed, MEDLINE and EMCARE. A broad search strategy was used, and the evidence evaluated and graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence.Seizure frequency varies between 10-40% in patients with Brain Metastases (BM) and from 30% (high-grade gliomas) to 90% (low-grade gliomas) in patients with PBT. In patients with BM, risk factors include number of BM and melanoma histology. In patients with PBT, BTRE is more common in patients with lower grade histology, frontal and temporal tumours, presence of an IDH mutation and cortical infiltration.All patients with BTRE should be treated with ASMs. Non-enzyme inducing ASMs are recommended as first line treatment for BTRE, but up to 50% of patients with BTRE due to PBT remain resistant. There is no proven benefit for the use of prophylactic ASMs, although there are no randomised trials testing newer agents. Surgical and oncological treatments i.e. radiotherapy and chemotherapy improve BTRE. Vagus Nerve Stimulation has been used with partial success.The review highlights the relative dearth of high-quality evidence for the management of BTRE and provides a framework for further studies aiming to improve seizure control, quality of life, and indications for ASMs.

Effectiveness and tolerability of brivaracetam in patients with epilepsy stratified by comorbidities and etiology in the real world: 12-month subgroup data from the international EXPERIENCE pooled analysis

“…Poor response to treatment has been associated with psychiatric comorbidities [ 8 ], and some ASMs are reported to cause psychiatric side effects [ 9 , 10 ]. There is limited evidence to support the choice of ASMs for specific etiologies such as post-stroke epilepsy and TBIE; however, for BTRE, the use of non–enzyme-inducing ASMs is recommended [ 23 ].…”

“…Management of BTRE is complex, due to the high incidence of drug resistance in these patients and the use of antineoplastic medication concomitantly with ASMs, which increases the risk of drug–drug adverse events [ 23 ]. To avoid interference with antineoplastic drugs, non–enzyme-inducing ASMs, such as LEV and lamotrigine, are recommended as first-line treatment for BTRE [ 23 ]. BRV is a non–enzyme-inducing ASM and therefore may be beneficial to patients with BTRE over other enzyme-inducing ASMs.…”

Vagus nerve stimulation in epilepsy – literature review

“…VNS should only be used in patients for whom other oncological treatments have been excluded, as the use of this method limits the ability to perform magnetic resonance imaging (MRI) for oncological control, and involves a specialized procedure to remove the conduits prior to scanning [21].…”