Epilepsy in patients with brain tumours: epidemiology, mechanisms, and management

Potential role for valproate in the treatment of high--risk brain tumors of childhood-results from a retrospective observational cohort study

Although substantial progress has been made in pediatric brain tumor management, patients with brainstem tumors and high-grade gliomas, as well as patients less than 3 years of age with high-risk malignant tumors, have a poorer prognosis. The authors have been treating these patients with radiotherapy and standard carboplatin and vincristine chemotherapy. Since January 2007 the authors have been using valproate as anticonvulsant for prophylaxis. The authors performed a retrospective cohort analysis of pediatric patients with high-risk brain tumors treated with chemotherapy, radiotherapy, and valproate prophylaxis, comparing this group with a historical control. The 2007-2008 group was comprised of 22 patients, 15 with brainstem tumors (7 diffuse intrinsic pontine glioma [DIPG], 3 focal, the remaining infiltrating with a solid portion), 4 with diencephalic tumors (2 thalamic), and 3 with supratentorial high-grade tumors (1 glioblastoma, 1 recurrent grade III ependymoma, 1 with gliomatosis). There were 15 patients alive (68%) after a mean follow-up time of 19 months. Survival function comparison by log rank test was highly significant (P = .004) with a hazard ratio of 0.31 (0.14-0.70). Radiological response showed 3 complete responses (14%), 8 partial responses (36%), 5 stable diseases (23%), and 5 progresssive diseases (23%). The authors hypothesize that valproate may have potentiated the antiangiogenic effect of vincristine, diminished expression of resistance to carboplatin, and sensitized tumor cells to radiotherapy. The authors suggest that clinical trials of carboplatin and vincristine associated with oral continuous low-dose valproate are indicated for pediatric patients with high-risk brain tumor.

Canine intracranial neoplasia: clinical risk factors for development of epileptic seizures

OBJECTIVES

To identify clinical risk factors for seizures in dogs with intracranial neoplasia.

METHODS

A cross-sectional retrospective study of 68 dogs with histopathologically confirmed primary or secondary intracranial neoplasia, complete clinical history and magnetic resonance imaging of the brain was conducted. Signalment and clinical history were retrieved from clinical records and magnetic resonance images of the brain were re-evaluated. Prevalence of findings was compared between dogs with and without seizures.

RESULTS

Forty-two dogs had tumour-related seizures, the remaining 26 were seizure-free. Tumour types included meningioma (23 dogs with and 5 without seizures), glioma (9 dogs with and 6 without seizures), choroid plexus tumour (2 dogs without seizures), neuroblastoma (1 dog with seizures) and metastatic/invasive tumours including lymphoma (9 dogs with and 13 without seizures). On the basis of multi-variable logistic regression analysis, risk factors for seizures associated with intracranial neoplasia were magnetic resonance imaging findings consistent with the presence of neoplastic tissue in frontal lobe [odds ratio (OR) 9·61; 95% confidence interval (CI) 2·59 to 35·61], marked gadolinium enhancement (OR 10·41; 95% CI 2·07 to 52·30) and magnetic resonance imaging findings of subfalcine and/or subtentorial herniation (OR 3·88; 95% CI 1·10 to 13·71).

CLINICAL SIGNIFICANCE

Dogs with primary or secondary intracranial neoplasia are at risk of seizures, particularly those with tumours that affect the frontal lobe, enhance markedly with gadolinium, or cause subfalcine and/or subtentorial herniation.

Factors associated with seizure freedom in the surgical resection of glioneuronal tumors

PURPOSE

Gangliogliomas (GGs) and dysembryoplastic neuroepithelial tumors (DNETs) are low-grade brain tumors of glioneuronal origin that commonly present with seizures. Achieving seizure control in patients with glioneuronal tumors remains underappreciated, as tumor-related epilepsy significantly affects patients' quality-of-life.

METHODS

We performed a quantitative and comprehensive systematic literature review of seizure outcomes after surgical resection of GGs and DNETs associated with seizures. We evaluated 910 patients from 39 studies, and stratified outcomes according to several potential prognostic variables.

KEY FINDINGS

Overall, 80% of patients were seizure-free after surgery (Engel class I), whereas 20% continued to have seizures (Engel class II-IV). We observed significantly higher rates of seizure-freedom in patients with ≤1 year duration of epilepsy compared to those with >1 year of seizures [odds ratio (OR) 9.48; 95% confidence interval (CI) 2.26-39.66], and with gross-total resection over subtotal lesionectomy (OR 5.34; 95% CI 3.61-7.89). In addition, the presence of secondarily generalized seizures preoperatively predicted a lower rate of seizure-freedom after surgery (OR 0.40; 95% CI 0.24-0.66). Outcomes did not differ significantly between adults and children, patients with temporal lobe versus extratemporal tumors, pathologic diagnosis of GG versus DNET, medically controlled versus refractory seizures, or with the use of electrocorticography (ECoG). Extended resection of temporal lobe tumors, with hippocampectomy and/or corticectomy, conferred additional benefit.

SIGNIFICANCE

These results suggest that early operative intervention and gross-total resection are critically important factors in achieving seizure-freedom, and thus improving quality-of-life, in patients with glioneuronal tumors causing epilepsy.

Prophylactic antiepileptic drug therapy in patients undergoing supratentorial meningioma resection: a systematic analysis of efficacy

Object

Meningiomas are one of the more common intracranial neoplasms. The risk of seizures and secondary aspiration, brain edema, and brain injury often leads practitioners to administer prophylactic antiepileptic drugs (AEDs) perioperatively. The efficacy of this practice remains controversial, however, with prior investigations reaching conflicting results and recent studies focusing on AED side effects. The authors performed a systematic analysis of outcomes following supratentorial meningioma resection with and without prophylactic AED administration in the hope of clarifying the role of AEDs in the perioperative care of patients with these lesions.

Methods

A MEDLINE search of the literature (1979–2010) was performed. Comparisons were made for patient and tumor characteristics as well as success of repair, morbidity, and seizure outcome. Statistical analyses of categorical variables were undertaken using chi-square and Fisher exact tests.

Results

Nineteen studies, involving 698 patients, were included. There were no significant differences in the extent of resection, perioperative mortality, or recurrence between the AED and no-AED cohorts. Likewise, there were no significant differences in the incidence of early or late seizures between the cohorts.

Conclusions

The results of this systematic analysis supports the conclusion that the prophylactic administration of anticonvulsants during resection of supratentorial meningiomas provides no benefit in the prevention of either early or late postoperative seizures. Despite their traditional role in this patient population, the routine use of AEDs should be carefully reconsidered.

Anomalous levels of Cl- transporters cause a decrease of GABAergic inhibition in human peritumoral epileptic cortex

PURPOSE

Several factors contribute to epileptogenesis in patients with brain tumors, including reduced γ-aminobutyric acid (GABA)ergic inhibition. In particular, changes in Cl(-) homeostasis in peritumoral microenvironment, together with alterations of metabolism, are key processes leading to epileptogenesis in patients afflicted by glioma. It has been recently proposed that alterations of Cl(-) homeostasis could be involved in tumor cell migration and metastasis formation. In neurons, the regulation of intracellular Cl(-) concentration ([Cl(-) ](i) ) is mediated by NKCC1 and KCC2 transporters: NKCC1 increases while KCC2 decreases [Cl(-) ](i) . Experiments were thus designed to investigate whether, in human epileptic peritumoral cortex, alterations in the balance of NKCC1 and KCC2 activity may decrease the hyperpolarizing effects of GABA, thereby contributing to epileptogenesis in human brain tumors.

METHODS

Membranes from peritumoral cortical tissues of epileptic patients afflicted by gliomas (from II to IV WHO grade) and from cortical tissues of nonepileptic patients were injected into Xenopus oocytes leading to the incorporation of functional GABA(A) receptors. The GABA-evoked currents were recorded using standard two-microelectrode voltage-clamp technique. In addition, immunoblot analysis and immunohistochemical staining were carried out on membranes and tissues from the same patients.

KEY FINDINGS

We found that in oocytes injected with epileptic peritumoral cerebral cortex, the GABA-evoked currents had a more depolarized reversal potential (E(GABA) ) compared to those from nonepileptic healthy cortex. This difference of E(GABA) was abolished by the NKCC1 blocker bumetanide or unblocking of KCC2 with the Zn(2+) chelator TPEN. Moreover, Western blot analysis revealed an increased expression of NKCC1, and more modestly, of KCC2 transporters in epileptic peritumoral tissues compared to nonepileptic control tissues. In addition, NKCC1 immunoreactivity was strongly increased in peritumoral cortex with respect to nonepileptic cortex, with a prominent expression in neuronal cells.

SIGNIFICANCE

We report that the positive shift of E(GABA) in epileptic peritumoral human cortex is due to an altered expression of NKCC1 and KCC2, perturbing Cl(-) homeostasis, which might lead to a consequent reduction in GABAergic inhibition. These findings point to a key role of Cl(-) transporters KCC2 and NKCC1 in tumor-related epilepsy, suggesting a more specific drug therapy and surgical approaches for the epileptic patients afflicted by brain tumors.

Prolonged survival with valproic acid use in the EORTC/NCIC temozolomide trial for glioblastoma

OBJECTIVE

This analysis was performed to assess whether antiepileptic drugs (AEDs) modulate the effectiveness of temozolomide radiochemotherapy in patients with newly diagnosed glioblastoma.

METHODS

The European Organization for Research and Treatment of Cancer (EORTC) 26981-22981/National Cancer Institute of Canada (NCIC) CE.3 clinical trial database of radiotherapy (RT) with or without temozolomide (TMZ) for newly diagnosed glioblastoma was examined to assess the impact of the interaction between AED use and chemoradiotherapy on survival. Data were adjusted for known prognostic factors.

RESULTS

When treatment began, 175 patients (30.5%) were AED-free, 277 (48.3%) were taking any enzyme-inducing AED (EIAED) and 135 (23.4%) were taking any non-EIAED. Patients receiving valproic acid (VPA) only had more grade 3/4 thrombopenia and leukopenia than patients without an AED or patients taking an EIAED only. The overall survival (OS) of patients who were receiving an AED at baseline vs not receiving any AED was similar. Patients receiving VPA alone (97 [16.9%]) appeared to derive more survival benefit from TMZ/RT (hazard ratio [HR] 0.39, 95% confidence interval [CI] 0.24-0.63) than patients receiving an EIAED only (252 [44%]) (HR 0.69, 95% CI 0.53-0.90) or patients not receiving any AED (HR 0.67, 95% CI 0.49-0.93).

CONCLUSIONS

VPA may be preferred over an EIAED in patients with glioblastoma who require an AED during TMZ-based chemoradiotherapy. Future studies are needed to determine whether VPA increases TMZ bioavailability or acts as an inhibitor of histone deacetylases and thereby sensitizes for radiochemotherapy in vivo.

Antiepileptic drugs for treating seizures in adults with brain tumours

BACKGROUND

Seizures are a common symptom of brain tumours. The mainstay of treatment for seizures is medical therapy with antiepileptic drugs.

OBJECTIVES

To evaluate the relative effectiveness and tolerability of antiepileptic drugs commonly used to treat seizures in adults with brain tumours.

SEARCH STRATEGY

We searched CENTRAL (Issue 2 of 4, The Cochrane Library 2011), MEDLINE (1948 to May week 3, 2011) and EMBASE (1980 to 31 May 2011) databases. In addition, we handsearched articles published since 2000 in the following journals selected by the authors: Epilepsia; The Lancet Neurology and Neuro-Oncology.

SELECTION CRITERIA

Controlled clinical trials with random allocation of the use of antiepileptic drugs to treat seizures in adults with brain tumours.

DATA COLLECTION AND ANALYSIS

Both review authors screened the search results and reviewed the abstracts of potentially relevant articles before retrieving the full text of eligible articles.

MAIN RESULTS

Only one trial met the inclusion criteria for this review which was a small, open-label, unblinded, randomised trial of the safety and feasibility of switching from phenytoin to levetiracetam monotherapy or continuing phenytoin for glioma-related seizure control following craniotomy (Lim 2009). Levetiracetam (a non enzyme-inducing antiepileptic drug) appears to have been at least as well tolerated and as effective as phenytoin (an enzyme-inducing antiepileptic drug) for the treatment of seizures in people with brain tumours. Eighty-seven per cent of participants treated with levetiracetam were free of seizures at six months compared with 75% of participants treated with phenytoin. There is one ongoing study of levetiracetam versus pregabalin for the treatment of seizures in adults undergoing chemotherapy, radiotherapy,or both for primary brain tumours. No data from this study were available at the time of preparing this review.

AUTHORS' CONCLUSIONS

There is a lack of robust, randomised, controlled evidence to support the choice of antiepileptic drug for the treatment of seizures in adults with brain tumours. While some authors support the use of non enzyme-inducing antiepileptic drugs, reliable, comparative evidence to provide clinical justification for this is limited. There is a need for further large, randomised, controlled trials in this area.

Surgical management of glioneuronal tumors with drug-resistant epilepsy

In this review, we discuss the options for the surgical management of glioneuronal tumors (GNTs) associated with drug-resistant epilepsy, with an emphasis on the surgical issues involved in addressing the epileptogenic nature of these lesions. We briefly summarize the pathological hallmarks of these lesions in order to outline how these tumors contribute to seizure activity. Understanding the pathophysiology of these lesions is important in discussing the advantages and disadvantages of different surgical strategies. There have been a number of studies that have investigated the utility of different surgical approaches in improving seizure outcome, and we highlight some of these studies in order to shed light on surgical issues related to these tumors.

Perioperative seizure incidence and risk factors in 223 pediatric brain tumor patients without prior seizures

OBJECT

The incidence of, and risk factors for, perioperative seizures and the need for perioperative antiepileptic drugs (AEDs) in previously seizure-free children with brain tumors remains unclear. The authors have undertaken a review of previously seizure-free pediatric patients with brain tumors undergoing resection to identify the incidence of seizures in the perioperative period, and to characterize risk factors for perioperative seizures in this population.

METHODS

A retrospective review was conducted of all patients between 0 and 19 years of age without prior seizures who underwent intracranial tumor resection at the authors' institution between January 2005 and December 2009.

RESULTS

Of the 223 patients undergoing 229 operations, 7.4% experienced at least 1 clinical seizure during the surgical admission. Over half of all tumors were supratentorial. Only 4.4% of patients received prophylactic AEDs. Independent factors associated with perioperative seizures included supratentorial tumor, age < 2 years, and hyponatremia due to syndrome of inappropriate antidiuretic hormone or cerebral salt wasting. Tumor type, lobe affected, operative blood loss, and length of surgery were not independently associated with seizure incidence.

CONCLUSIONS

Perioperative seizures in previously seizure-free children undergoing resection of brain tumors are associated with supratentorial tumor location, age < 2 years, and postoperative hyponatremia. Perioperative seizures are not associated with tumor pathology, tumor size, or frontotemporal location. Due to the low incidence of seizures in this series in patients more than 2 years old with normal serum sodium, the authors recommend that pediatric patients with brain tumors not routinely receive perioperative prophylactic AEDs. However, the role for prophylaxis in patients younger than 2 years of age deserves further study.

Etiologies of epilepsy: a comprehensive review

Epilepsy is a heterogeneous disorder, the symptoms of which are preventable and controllable to some extent. Significant inter- and intra-country differences in incidence and prevalence exist because multiple etiologic factors are implicated. Many past reviews have addressed sole etiologies. We considered a comprehensive view of all etiologies (genetic/structural/metabolic) to be significant for both the developing and the developed world as well as routine clinical/epidemiology practice. We therefore carried out a comprehensive search for peer-reviewed articles (irrespective of year, region and language; chosen based on novelty and importance) for each etiology. This article was felt to be essential since newer etiologic knowledge has emerged in recent years. Many new genetic links for rarer epilepsy forms have emerged. Epilepsy risk in limbic encephalitis, mechanisms of Alzheimer's-related epilepsy and the genetic basis of cortical malformations have been detailed. An etiological approach to epilepsy in combination with the conventional classification of epilepsy syndromes is required to gain knowledge.

Frontier of epilepsy research - mTOR signaling pathway

Studies of epilepsy have mainly focused on the membrane proteins that control neuronal excitability. Recently, attention has been shifting to intracellular proteins and their interactions, signaling cascades and feedback regulation as they relate to epilepsy. The mTOR (mammalian target of rapamycin) signal transduction pathway, especially, has been suggested to play an important role in this regard. These pathways are involved in major physiological processes as well as in numerous pathological conditions. Here, involvement of the mTOR pathway in epilepsy will be reviewed by presenting; an overview of the pathway, a brief description of key signaling molecules, a summary of independent reports and possible implications of abnormalities of those molecules in epilepsy, a discussion of the lack of experimental data, and questions raised for the understanding its epileptogenic mechanism.

The effect of topiramate on tumor-related angiogenesis and on the serum proteome of mice bearing Lewis lung carcinoma

Topiramate has been used in patients with brain tumors who develop epilepsy. In our previous research we found topiramate could inhibit tumor metastases of Lewis lung carcinoma in C57BL/6 mice. In this study we aimed to assess the antimetastatic activity of topiramate and determine its mechanism of action. After confirming the effects of topiramate on Lewis lung carcinoma in C57BL/6 mice, we assessed the mRNA expression of carbonic anhydrases II and IX, and the vascular endothelial growth factor (VEGF) distribution in tumor tissue. We studied the role of topiramate on primary angiogenesis using a chicken embryo chorioallantoic membrane angiogenesis model, and analyzed the protein profile of serum from mice treated with or without topiramate by two-dimensional electrophoresis. We found that topiramate significantly reduced the primary tumor growth (P<0.05) and the degree of damage to the lung alveoli caused by metastatic tumor deposits. The two-dimensional electrophoresis revealed changes that occurred with topiramate treatment and four down-regulated protein spots were clearly identified as tropomyosin, osteopontin, transthyretin, and serum amyloid A-1. The mRNA and protein expression of serum amyloid A-1, osteopontin and its receptor, integrin α(v)β(3) in tumor tissue were reconfirmed. The results suggest that topiramate has antitumor and antimetastatic effects on Lewis lung carcinoma. Its mechanism of action may be related to its inhibition of angiogenesis by down-regulation of osteopontin, VEGF and carbonic anhydrase II.

Predictors of seizure freedom after resection of supratentorial low-grade gliomas. A review

OBJECT

Seizures are the most frequent presenting symptom in patients with low-grade gliomas (LGGs), and significantly influence quality of life if they are uncontrolled. Achieving freedom from seizures is of utmost importance in surgical planning, but the factors associated with seizure control remain incompletely understood.

METHODS

The authors performed a systematic literature review of seizure outcomes after resection of LGGs causing seizures, examining 773 patients across 20 published series. Rates of seizure freedom were stratified across 7 variables: patient age, tumor location, preoperative seizure control with medication, seizure semiology, epilepsy duration, extent of resection, and the use of intraoperative electrocorticography (ECoG).

RESULTS

Gross-total resection was most predictive of complete seizure freedom, when compared with subtotal resection (OR 3.41, 95% CI 2.36-4.93). Other predictors of seizure freedom included preoperative seizure control on antiepileptic medication (OR 2.12, 95% CI 1.33-3.38) and duration of seizures of ≤ 1 year (OR 1.85, 95% CI 1.22-2.79). Patients with simple partial seizure semiology achieved seizure freedom less often than those with complex partial, generalized, or mixed seizure types (OR 0.46, 95% CI 0.26-0.80). No significant differences in seizure outcome were observed between adults versus children, patients with temporal lobe versus extratemporal tumors, or with the use of intraoperative ECoG.

CONCLUSIONS

Seizure control is one of the most important considerations in planning surgery for low-grade brain tumors. Gross-total resection is a critical factor in achieving seizure freedom.

Postoperative seizure in high grade glioma patients treated with BCNU wafers. A mono-institutional experience

Anticonvulsant therapy is usually recommended before surgery in all patients affected by high grade glioma who are planned to be treated with Carmustine 1,3-bis [2 chloroetyl]-1-nitrosurea, or BCNU) wafers. In fact, phase III studies have reported a risk of seizures higher than 30% in this group of patients. The aim of the study was the evaluation of rate type time of occurrence of seizures in BCNU-treated patients in the postoperative period as well as the investigation into possible risk factors for seizure occurrence in this population. From April 2007 to September 2010, 55 patients underwent surgical removal of malignant glioma and BCNU wafers implantation at the Department of Neurosurgery of Padova. All patients were given antiepileptic prophylaxis for 3 months after surgery. Clinical data (including preoperative seizure history), radiological data, surgical treatment, antiepileptic treatment were retrospectively reviewed. Nine percent of the patients treated with BCNU wafers presented seizures in the postoperative course. Seizures were partial in 80% of cases; they occurred within 30 days after surgery and in 80% of cases within the first 7 days. Patients with preoperative seizures presented more frequently postoperative epilepsy than patients who were preoperatively seizure-free [P = 0.0006; OR = 48 (2,4;945)]. Postoperative seizures were more common among patients affected by one or more wafers related adverse event than among patients without adverse events [P = 0.006; OR = 21 (2,06;213)]; however, they did not appear associated to the number of implanted wafers. Patients with a sub-therapeutic level of AED at the seventh day after surgery presented a higher seizure occurrence [P = 0.02; OR = 11 (1,5;79,8)]. In our experience, postoperative seizures in BCNU-treated patients were less frequent than expected. Careful patient selection and postoperative monitoring could probably play a role in order to decrease seizure occurrence.

[Primary brain tumors and brain metastases. Symptomatic epilepsy and driving ability - systematic review and expert opinion]

PURPOSE

Primary brain tumors and metastases are common causes of symptomatic epilepsy. Seizures, neurological and neuropsychological deficits can interfere with driving ability. The present paper aims to systematically review the incidence of epileptic seizures in brain tumor patients and to discuss driving ability in the context of the current German guidelines and expert opinions.

METHODS

To evaluate the incidence of epileptic seizures which occur at the beginning and in the course of the disease, we performed a systematic literature research in PubMed from 1960 to 2007. Additionally on the basis of this data we performed a survey collecting expert opinions regarding the driving ability of brain tumor patients from members of the German working groups "Arbeitsgemeinschaft für prächirurgische Epilepsiediagnostik und operative Epilepsietherapie" (Working Group for Presurgical Epilepsy Diagnostics and Operative Epileptic Therapy) and "Neuroonkologische Arbeitsgemeinschaft" (Neuro-oncological Working Group).

RESULTS

The incidence of epileptic seizures depends on the entity, dignity and localization of the tumor. The driving ability of brain tumor patients is not explicitly regulated in Germany. Of the interviewed experts 72% judged the guidelines to be precise enough and 44% did not want to deprive the patients of their driving ability without a first seizure, independent of the individual risk.

DISCUSSION

The available studies are methodologically insufficient and show that a further evaluation is necessary to assess the driving ability. Possible restrictions of the driving ability in patients with a high risk of seizures in the course of the disease have to take into account the balance between individual rights and the interests of the general public.

[High-grade gliomas in adults]

BACKGROUND

High-grade glioma is a primary malignant brain tumour which affects about 200 Norwegian patients each year. Diagnosis and treatment of high-grade gliomas in adults has been reviewed.

MATERIAL AND METHODS

The article is based on recent literature retrieved through a non-systematic search in PubMed and the authors' experience with the patient group.

RESULTS

The most common symptoms are focal neurological deficits, epileptic seizures and pressure symptoms. The patients should be examined by magnetic resonance (MR) imaging and the diagnosis confirmed with biopsy. No curative treatment is currently available for high-grade gliomas. The standard treatment is surgical resection followed by radiation therapy alone or in combination with chemotherapy (temozolomid). Five-year survival is only 6.1 %.

INTERPRETATION

The diagnosis is composite with both neurological symptoms and cognitive problems. This requires good communication with the patient and close cooperation between various departments and the primary health services. Symptomatic treatment and multidisciplinary follow-up is necessary.

Epilepsy in the cancer patient

PURPOSE

Epileptic seizures in patients with malignancies usually occur as a consequence of brain metastases from systemic cancer or the presence of a primary brain tumor. Other less-frequent causes include metabolic disorders such as electrolyte abnormalities, hypoglycemia, hypoxia and liver failure, paraneoplastic encephalitis, leptomeningeal carcinomatosis, side effects of certain chemotherapeutic agents, central nervous system infections, and pre-existing epilepsy.

METHODS

We reviewed all published literature in the English language regarding the use of antiepileptic drugs in patients with cancer.

RESULTS

In patients with brain metastases or primary brain tumors that had never experienced seizures, prophylactic anticonvulsant treatment is justified only for a period up to 6 months postoperatively after surgical excision of a cerebral tumor, since approximately half of the patients will never develop seizures and the anti-epileptic drugs may cause toxicity and interactions with antineoplastic therapies. For brief prophylaxis, newer antiepileptic drugs such as levetiracetam and oxcarbazepine are superior to older agents like phenytoin. In patients with a malignancy and seizures, certain antiepileptic drugs that express tumor inhibitory properties should be used such as valproic acid and levetiracetam, followed by oxcarbazepine and topiramate that exhibit good tolerance, efficient seizure control and absence of significant interactions with the chemotherapy.

CONCLUSIONS

Future clinical trials in patients with cancer and epilepsy should focus on combinations of chemotherapeutic interventions with antiepileptic drugs that demonstrate antineoplastic activities.

Antiepileptic drug therapy in the perioperative course of neurosurgical patients

PURPOSE OF REVIEW

Antiepileptic agents are widely used in the perioperative course of neurosurgical patients - for prophylactic and therapeutic reasons. However, the evidence supporting their use is extremely small and adverse events are common. This review highlights the current controversies.

RECENT FINDINGS

Prophylactic use of antiepileptic agents is unfavorable for patients with subarachnoid hemorrhage. In patients with brain tumors, prophylactic use is not recommended. If the drugs are used nevertheless, stopping after the first postoperative week must be strongly recommended. After traumatic brain injury, early prophylactic use might prevent late post-traumatic seizures. The new antiepileptic drug levetiracetam seems to have a better safety profile, which makes it more suitable for prophylactic use. However, in all groups, evidence concerning the choice of drugs and duration of prophylaxis is lacking. Current research is focusing on prevention of epileptogenesis. Therapeutic use of antiepileptic drugs is supported by evidence. These drugs should be continued perioperatively. However, they might induce severe adverse events during adjuvant treatments like radiotherapy or chemotherapy in patients with brain tumors.

SUMMARY

Despite lacking evidence, prophylactic antiepileptic drug use is common in the perioperative course of neurosurgical patients. More research is needed to deal better with epileptogenesis and to define the right drug for the right patient at the right time.

Neurologist vs the neurosurgeons: who is the NICEst? The medical management of the neurosurgical patient with seizures

Seizures and epilepsy are a relatively common occurrence in the neurosurgical patient. Neurosurgeons are often involved in the medical management utilising anti-epileptic drugs (AEDs). There is a distinct lack of contemporary literature in relation to management of seizures/epilepsy in the neurosurgical patient, in particular, for the newer AEDs. In the UK, clinical practice guidelines have been issued from both the National Institute for Health and Clinical Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) in relation to epilepsy in primary and secondary care. We sought to determine current management practice for neurosurgical patients with epilepsy/seizures. The relevance of the issued guidelines was examined within the neurosurgical setting. An audit by telephone survey was conducted in Neurosurgical and Neurology units in the UK. Respondents were asked about the management of patients in two clinical scenarios. We received 25 responses from the neurosurgical and 22 responses from the neurology communities. Management of the patient scenarios is described and is further considered in relation to the published guidelines. There was considerable disparity between the guidelines and the management strategies pursued by both groups. We conclude that the standard of treatment is sub-optimal in many cases. The guidelines have not had a significant influence and are not felt to be strictly relevant within the neurosurgical setting. The development of guidelines relevant to the neurosurgical setting is proposed. Further research within this field and investment in education for neurosurgeons relating to AED therapy is advocated. The neurologists responses were more closely aligned to the guidelines and so they were deemed the 'NICEst'.

Epilepsy and brain tumors

PURPOSE OF REVIEW

To present an overview of the recent findings in pathophysiology and management of epileptic seizures in patients with brain tumors.

RECENT FINDINGS

Low-grade gliomas are the most epileptogenic brain tumors. Regarding pathophysiology, the role of peritumoral changes [hypoxia and acidosis, blood-brain barrier (BBB) disruption, increase or decrease of neurotransmitters and receptors] are of increasing importance. Tumor-associated epilepsy and tumor growth could have some common molecular pathways. Total/subtotal surgical resection (with or without epilepsy surgery) allows a seizure control in a high percentage of patients. Radiotherapy and chemotherapy as well have a role. New antiepileptic drugs are promising, both in terms of efficacy and tolerability. The resistance to antiepileptic drugs is still a major problem: new insights into pathogenesis are needed to develop strategies to manipulate the pharmakoresistance.

SUMMARY

Epileptic seizures in brain tumors have been definitely recognized as one of the major problems in patients with brain tumors, and need specific and multidisciplinary approaches.

Levetiracetam monotherapy in patients with brain tumor-related epilepsy: seizure control, safety, and quality of life

We performed a case series analysis to evaluate the effects of levetiracetam (LEV) monotherapy on seizures, adverse events, cognitive functioning and quality of life (QoL) in patients with brain tumor-related epilepsy (BTRE). We also explored the possible effects of systemic therapies on the efficacy of LEV. Twenty-nine patients were followed (13 female, 16 male; age 24-75 years) with 12 months of follow-up. Patients were evaluated by QoL and neuropsychological tests. At final follow-up, mean LEV dosage was 1991.4 mg/day. Among patients who reached the final follow-up of 12 months (n = 15), 1 patient had ≥50% reduction of seizure frequency (SF), and 14/15 were seizure free. The difference in presence/absence of seizures between baseline and final follow-up was significant (p < 0.001). Responder rate was 100%. We observed five side-effects: four mild (reversible) and one severe. Logistic regression revealed that chemotherapy and radiotherapy did not affect the efficacy of LEV in seizure outcome (p = 0.999). The following statistically significant observations emerged by tests' evaluation: less worry about seizures, effects of antiepileptic, and ability to maintain social functions. Our data suggest that seizure occurrence can be an important warning sign that the clinician should heed throughout the duration of the illness. Patients with BTRE represent a unique patient population that presents difficulties regarding management of two very different pathologies: epilepsy on the one hand, and brain tumor on the other. Our data indicate that LEV, in patients with BTRE, is safe and efficacious, with positive impact on QoL.

Treatment initiation in epilepsy: an expert consensus in Spain

OBJECTIVE

The goals of this study were to explore the diverse criteria surrounding indications for antiepileptic therapy and to establish a consensus on drug selection for initial monotherapy in adult patients with epilepsy.

METHODS

The study was performed using the modified Delphi method, which aims to achieve professional consensus by means of a series of questionnaires. Three different groups of items were evaluated: the beginning of antiepileptic treatment, the drug selected for initial monotherapy with respect to the type of epilepsy, and the drug selected for initial monotherapy with respect to comorbidity.

RESULTS

Sixty experts completed two rounds of a questionnaire. In the first round, consensus was reached on 135 of the 194 questions analyzed. After the second round, consensus was reached on 148 items. The main findings of the survey revealed a consensus on beginning treatment after the first seizure when the EEG showed abnormalities such as generalized spike-wave discharges, when MRI demonstrated an epileptogenic brain lesion, and in elderly patients. Regarding to the antiepileptic drug selected for initial monotherapy with respect to type of epilepsy, levetiracetam and lamotrigine were recommended for generalized tonic-clonic seizures regardless of sex or age; levetiracetam was recommended for myoclonic epilepsy regardless of sex; valproic acid, ethosuximide, levetiracetam, and lamotrigine were chosen for absence epilepsy; and carbamazepine, levetiracetam, lamotrigine, and oxcarbazepine were recommended for partial epilepsy regardless of age or sex. Finally, in the evaluation of drug selection with respect to comorbidity, first-generation drugs were less recommended than second-generation drugs, which were clearly preferable. The drugs on which there was a greater consensus were levetiracetam, lamotrigine, valproic acid, and topiramate.

CONCLUSIONS

There is a tendency to begin treatment after the first seizure, depending on the results of additional testing. In general, first-generation drugs are less recommended for different types of epilepsy, especially in the presence of a comorbid condition. However, the authors are conveying perceptions and opinions, the effect of which on treatment outcomes has not been evaluated.

Cerebral edema, altered mental status, seizures, acute stroke, leptomeningeal metastases, and paraneoplastic syndrome

Neurologic symptoms commonly occur in oncology patients, and in some cases they may be the presenting symptom of malignancy. Cancer-related neurologic syndromes are rarely pathognomonic and must be differentiated from other benign or serious conditions. This article reviews common neuro-oncologic syndromes that may lead to urgent evaluation in the emergency department, including cerebral edema, altered mental status, seizures, acute stroke, leptomeningeal metastases, and paraneoplastic neurologic syndromes.

Perioperative levetiracetam for prevention of seizures in supratentorial brain tumor surgery

Efficacy and tolerability of levetiracetam (LEV) as perioperative seizure prophylaxis in supratentorial brain tumor patients were retrospectively studied. Between February 2007 and April 2009 in a single institution, 78 patients with primary or secondary supratentorial brain tumors [40 female, 38 male; mean age 57 years, from 27 to 89 years; gliomas in 42 patients (53.8%), brain metastases in 17 (21.8%), meningiomas in 16 (20.5%), 1 primary central nervous system (CNS) lymphoma patient, and 2 patients with radiation necrosis] received between 1,000 mg and 3,000 mg LEV perioperatively. Preoperatively, 30 patients had experienced seizures (38.5%), most commonly glioma patients (47.6%), but also meningioma patients (31.3%) or patients with brain metastases (23.5%). No more seizures occurred in patients receiving 1-3 g LEV preoperatively. Within the first week postoperatively, a single seizure occurred in two patients (2.6%). At the end of the follow-up period (mean 10.5 months, range 0-31 months), 71 of the 78 patients (91%) were seizure free and 21 (26%) patients were not taking antiepileptic drugs. We observed side-effects in five patients (6.4%), including non-tumor-associated progressive somnolence in three patients (1.5 g, 1.5 g, and 2 g LEV daily) and reactive psychosis in two patients (1 and 1.5 g LEV daily), regressing after dose reduction. Perioperative LEV in supratentorial brain tumor patients was well tolerated. Compared with the literature, it resulted in low (2.6%) [corrected] seizure frequency in the early postoperative period. Additionally, its advantage of lacking cytochrome P450 enzyme induction allowed early initiation of effective postoperative chemotherapy in malignant glioma patients.

Morphological characteristics of brain tumors causing seizures

OBJECTIVE

To quantify size and localization differences between tumors presenting with seizures vs nonseizure neurological symptoms.

DESIGN

Retrospective imaging survey. We performed magnetic resonance imaging-based morphometric analysis and nonparametric mapping in patients with brain tumors.

SETTING

University-affiliated teaching hospital.

PATIENTS OR OTHER PARTICIPANTS

One hundred twenty-four patients with newly diagnosed supratentorial glial tumors.

MAIN OUTCOME MEASURES

Volumetric and mapping methods were used to evaluate differences in size and location of the tumors in patients who presented with seizures as compared with patients who presented with other symptoms.

RESULTS

In high-grade gliomas, tumors presenting with seizures were smaller than tumors presenting with other neurological symptoms, whereas in low-grade gliomas, tumors presenting with seizures were larger. Tumor location maps revealed that in high-grade gliomas, deep-seated tumors in the pericallosal regions were more likely to present with nonseizure neurological symptoms. In low-grade gliomas, tumors of the temporal lobe as well as the insular region were more likely to present with seizures.

CONCLUSIONS

The influence of size and location of the tumors on their propensity to cause seizures varies with the grade of the tumor. In high-grade gliomas, rapidly growing tumors, particularly those situated in deeper structures, present with non-seizure-related symptoms. In low-grade gliomas, lesions in the temporal lobe or the insula grow large without other symptoms and eventually cause seizures. Quantitative image analysis allows for the mapping of regions in each group that are more or less susceptible to seizures.

Preoperative antiepileptic drug administration and the incidence of postoperative seizures following bur hole-treated chronic subdural hematoma

OBJECT

Despite the prevalence of chronic subdural hematoma (CSDHs) in the rapidly growing elderly population, several aspects of disease management remain unclear. In particular, there is still conflicting evidence regarding the efficacy of antiepileptic drug (AED) prophylaxis in patients with CSDH who undergo bur hole drainage. The authors endeavored to evaluate the efficacy of AED prophylaxis in reducing the incidence of seizures and improving outcome in this patient population.

METHODS

A single surgeon's clinical database (E.S.C.) was analyzed for cases involving bur hole drainage for CSDH. Cases involving nonhemorrhagic subdural effusions as well as acute subdural hemorrhages evacuated by craniotomy were excluded from this study. Patient medical records were evaluated for relevant demographic data, medical history, imaging characteristics, clinical details of the treatment, hospital stay, and discharge summaries.

RESULTS

The authors included 88 patients with bur hole-treated CSDH. Eleven patients (12.5%) suffered at least 1 seizure between hemorrhage onset and discharge from their treatment hospital admission. Seizures were more frequent in women than men (p = 0.030) and least frequent in patients with right-sided lesions (p = 0.030). In a multiple logistic regression model, preoperative initiation of AED prophylaxis was the only significant predictor of the lower incidence of postoperative seizures (OR 0.10, p = 0.013). However, preoperative initiation of AED prophylaxis did not significantly affect outcome at discharge.

CONCLUSIONS

The finding in this study demonstrates that preoperative AED prophylaxis likely reduces the incidence of postoperative seizures in patients with CSDH treated with bur hole drainage. A future prospective randomized study is necessary to evaluate the effect of seizure reduction on clinical outcome.

Expression of synaptic vesicle protein 2A in epilepsy-associated brain tumors and in the peritumoral cortex

Synaptic vesicle protein 2A (SV2A) has been identified as the binding site for the antiepileptic drug levetiracetam and is thought to decrease neuronal excitability. Since knockout of SV2A in mice leads to seizures, we hypothesized that a reduction in SV2A expression promotes seizure generation in epilepsy-associated brain tumors. We compared the SV2A expression and distribution in surgically removed tumor tissue (n = 63) and peritumoral cortex (n = 31) of patients with glial and glioneuronal tumors to normal control cortex obtained at autopsy in nonbrain tumor patients (n = 6). Additionally, we compared the SV2A expression and distribution in tumor patients with epilepsy (n = 39) with SV2A expression in tumor patients without epilepsy (n = 24). Immunohistochemistry in control cortex demonstrated strong and diffuse SV2A immunoreactivity (IR) throughout all cortical layers. Similar strong SV2A IR (with the same diffuse distribution pattern) was observed in the peritumoral cortical specimens in both patients with and without epilepsy. Modest SV2A IR was observed within the tumor area. The SV2A-positive cells detected within the tumor area were mainly entrapped neurons. Oligodendrogliomas and glioneuronal tumors displayed variable SV2A neuropil staining. In ganglioglioma (GG), strong SV2A IR was present along the dysplastic neuronal cell borders and processes. In both GG and dysembryoplastic neuroepithelial tumors, SV2A IR was occasionally observed within the neuronal perikarya. We found no differences in SV2A expression in the peritumoral cortex between the patients with and without epilepsy, which suggests that the role of SV2A in epileptogenesis in patients with glial tumors is questionable. The distinct pattern of SV2A IR in glioneuronal tumors suggests a redistribution of SV2A.

Health-related quality of life aspects in patients with low-grade glioma

Standard therapeutic options for brain tumors include surgery, radiotherapy, and chemotherapy. Unfortunately, these same therapies pose risks of neurotoxicity, the most common long-term complications being radiation necrosis, chemotherapy-associated leukoencephalopathy, and cognitive deficits. Currently, there is no consensus on the treatment strategy for these tumors. Because of the relatively slow growth rate of low-grade gliomas, patients have a relatively long expected survival. Compared to traditional outcome measures like (progression-free) survival, evaluation of health-related quality of life may be time-consuming and burdensome for both the patient and the doctor. Besides, given the relatively low incidence of brain tumors and the ultimately fatal outcome of the disease, the interest in HRQOL emerged relatively late in these patients. Moreover, the notion that the disease itself may affect the patient's ability to judge his or her own functioning may hinder the use of patient self-reported measures. The studies presented in this chapter describe outcomes of both single dimensional and multidimensional methods of studying HRQOL. Although only few studies incorporated HRQOL as outcome measure, most studies have embraced the notion that an accurate assessment of HRQOL must be based on patient self-report. HRQOL instruments from other cancer groups are adapted for use with brain tumor patients. The multidimensional scales used to study changes in HRQOL studies in brain tumor patients provide a more comprehensive view of what is important to the patient concerning living with their disease and receiving treatment. In future trials, more sensitive measures of long-term cognitive, functional, and HRQOL outcomes on LGG patients at important time points over the disease trajectory are needed to better understand the changing needs that take place over time.

Seizures in patients with low-grade gliomas--incidence, pathogenesis, surgical management, and pharmacotherapy

Seizures complicate the clinical course of > 80% of patients with low-grade gliomas. Patients with some tumor variants almost always have epilepsy. Diffuse low-grade gliomas (LGG) are believed to cause epilepsy through partial deafferentiation of nearby brain cortex (denervation hypersensitivity). Glioneural tumors may interfere with local neurotransmitter levels and are sometimes associated with structural abnormalities of the brain which may produce seizures. The severity of tumor associated epilepsy varies considerably between patients. Some cases may present with a first seizure. Others suffer from long-standing pharmacoresistant epilepsy. Seizure control rates of > 70-80% can be expected after complete tumor resections. Patients with drug-resistant epilepsy require a comprehensive preoperative epileptological work-up which may include the placement of subdural (and intraparenchymal) electrodes or intraoperative electrocorticography (ECoG) for the delineation of extratumoral seizure foci. Partial and subtotal tumor resections are helpful in selected cases, i.e. for gliomas involving the insula. In one series, 40% of patients presented for surgery with uncontrolled seizures, i.e. medical therapy alone often fails to control tumor-related epilepsy. Use of the newer (second generation) non-enzyme inducing antiepileptic drugs (non-EIAED) is encouraged since they seem to have lesser interactions with other medications (e.g. chemotherapy). Chemotherapy and irradiation may have some minor beneficial effects on the patients' seizure disorder. Overall 60-70% of patients may experience recurrent epilepsy during long-term follow-up. Recurrent seizures (not infrequently heralding tumor recurrence) after surgery continue to pose significant clinical problems.

Brain tumors in the mesial temporal lobe: long-term oncological outcome

OBJECT

Surgical treatment of brain tumors in the mesial temporal lobe (MTL) is a highly demanding procedure. Only a few studies describing the surgery of MTL tumors have been reported, and they have been focused on the operative techniques and immediate results of the surgery. The authors have analyzed the long-term oncological outcome in patients with MTL tumors.

METHODS

Thirty-six patients with an MTL tumor were studied. The mean patient age at surgery was 32 years (range 13-62 years). The tumors were confined to the MTL (Schramm Type A) in 25 patients (69%). Extension of the tumor into the fusiform gyrus (Schramm Type C) and temporal stem (Schramm Type D) was observed in 4 and 7 patients (11 and 19%), respectively. There was a significant difference in the tumor size according to Schramm types (p = 0.001). Complete tumor resection was achieved in 26 patients (72%). All tumors were low-grade lesions except for 1 anaplastic astrocytoma.

RESULTS

After a median follow-up period of 50.5 months, 7 patients showed progression of the disease. The actuarial progression-free survival rates were 97% in the 1st year, 84% in the 2nd year, and 80% in the 5th year. The degree of tumor resection was significantly related to the tumor control failure (p < 0.001) and malignant transformation of a low-grade tumor (p < 0.001). Univariate analyses using a Cox proportional hazards model showed that the following factors were significantly associated with a failure to control the tumor: 1) extent of the tumor (Schramm Type D; p = 0.003, relative risk [RR] 12.04); 2) size of the tumor (p = 0.033, RR 1.052/mm); 3) patient age at surgery >or= 50 years (p = 0.007, RR 8.312); and 4) short duration of epilepsy (< 6 months; p = 0.001, RR 21.54).

CONCLUSIONS

Surgery is the principal treatment for MTL tumors, despite its technical difficulty. Complete tumor resection is strongly recommended for long-term tumor control. The MTL tumors are heterogeneous in their prognosis. Older age, short duration of epilepsy, and tumor size are all associated with poor outcome. Patients with these characteristics may have a more aggressive form of the disease than those with MTL tumors associated with chronic epilepsy.

Tumor-associated epilepsy

Tumor-associated epilepsy is an important contributor to morbidity in patients with brain tumors. Proposed pathophysiological mechanisms to explain these effects range from neuronal and glial dysfunction to deranged vascular homeostasis, to ionic and pH changes. Perilesional tissue alterations play a vital role in the generation of tumor-associated seizures. Clinical studies have determined that tumor-associated seizures are usually focal with secondary generalization and often resistant to antiepileptic drugs. Tumor histopathological characteristics and location are independent factors that impact seizure burden. Further understanding of the mechanisms of tumor-associated epilepsy may lead to new types of treatments targeted at perilesional tissue alterations.

Diagnosis of childhood astrocytomas

BACKGROUND

Astrocytomas are the most common brain tumours, accounting for 28 - 50% of all primary CNS tumours. Diagnosis of CNS tumours remains difficult because the varied and nonspecific presentations of CNS tumours in childhood. Objectives/method: The clinical presentations of CNS astrocytomas vary with their sites of location; therefore, a period of uncertainty often precedes diagnosis, and approximately 42% of patients with an intracranial process make several visits to various physicians between the onset and diagnosis. However, on clinical suspicion of a brain tumour, a wide range of neuroimaging techniques may be used to assess the diagnosis of paediatric brain lesions. In this review the authors, for ease of presentation, describe the clinical presentations of supratentorial, infratentorial and spinal cord astrocytomas as well as their radiological and pathological features, and discuss their differential diagnoses.

RESULTS/CONCLUSIONS

Understanding and mastering the numerous imaging features of several subtypes of primary brain tumours affecting children, in addition to radiological features of non-tumoural disorders, remains a significant challenge and demands increased awareness of the paediatric brain diseases.

The use of antiepileptic drugs in pediatric brain tumor patients

Antiepileptic drugs are frequently used in children with brain tumors. This retrospective study reviewed chronic use of antiepileptic drugs in children with brain tumors at two children's hospitals between 2000 and 2007. Antiepileptic drugs were used in 32/334 pediatric brain tumor patients (10%). Almost all (94%) had supratentorial tumors, of which 78% were glial tumors. The most common localization was temporal (70%). The most frequently used initial antiepileptic drugs were phenytoin (n = 14) and oxcarbazepine (n = 7). Initial antiepileptic drugs were frequently changed, because of lack of efficacy and adverse effects, as well as concerns about possible drug interactions. At last follow-up, the most common antiepileptic drugs were oxcarbazepine (n = 11) and levetiracetam (n = 10). Levetiracetam was more likely to be used in children who received chemotherapy or radiation therapy (8/14, or 57%) than in those who did not receive adjuvant therapies (3/18, or 17%) (P = 0.03). The patients started on newer-generation antiepileptic drugs (levetiracetam, oxcarbazepine, lamotrigine) tended to remain on the same antiepileptic drugs more than did patients on older-generation antiepileptic drugs (valproic acid, phenytoin, phenobarbital) (73% vs 28%) (P = 0.04). Newer antiepileptic drugs, especially those without significant drug-drug interactions, may be a more appropriate first choice in children with brain tumors and seizures.

Long-term seizure outcomes in adult patients undergoing primary resection of malignant brain astrocytomas

Object

Seizures are a common presenting symptom and cause of morbidity for patients with malignant astrocytomas. The authors set out to determine preoperative seizure characteristics, effects of surgery on seizure control, and factors associated with prolonged seizure control in patients with malignant astrocytomas.

Methods

Cases involving adult patients who underwent primary resection of a hemispheric anaplastic astrocytoma (AA) or glioblastoma multiforme (GBM) at the Johns Hopkins Medical Institutions between 1996 and 2006 were retrospectively reviewed. Multivariate logistical regression analysis was used to identify associations with pre-operative seizures, and multivariate proportional hazards regression analyses were used to identify associations with prolonged seizure control following resection.

Results

Of the 648 patients (505 with GBM, 143 with AA) in this series, 153 (24%) presented with seizures. The factors more commonly associated with preoperative seizures were AA pathology (p = 0.03), temporal lobe involvement (p = 0.04), and cortical location (p = 0.04), while the factors less commonly associated with preoperative seizures were greater age (p = 0.03) and larger tumor size (p ≤ 0.001). Among those patients with a history of seizures, outcome 12 months after surgery was Engel Class I (seizure free) in 77%, Class II (rare seizures) in 12%, Class III (meaningful improvement) in 6%, and Class IV (no improvement) in 5%. Postoperative seizures were rare in patients without a history of preoperative seizures. The factor positively associated with prolonged seizure control was increased Karnofsky Performance Scale score (p = 0.002), while the factors negatively associated with seizure control were preoperative uncontrolled seizures (p = 0.03) and parietal lobe involvement (p = 0.005). Seizure recurrence in patients with postoperative seizure control was independently associated with tumor recurrence (p = 0.006).

Conclusions

The identification and consideration of factors associated with prolonged seizure control may help guide treatment strategies aimed at improving the quality of life for patients with malignant astrocytomas.

Neurological comorbidity and epilepsy: implications for treatment

Epilepsy is a chronic condition that may be associated with several other diseases. In these cases, we should consider the following points: (1) antiepileptic drug (AED) treatment may positively or negatively affect comorbid disease, (2) drugs used for treatment of co-morbid disease may influence seizure threshold, (3) AED toxicity can be affected by a comorbid condition and (4) co-administration of AEDs with drugs used for treatment of comorbid conditions can be associated with clinically relevant drug-drug interactions. In this article, we discuss problems that are usually encountered when an appropriate AED treatment has to be selected in newly diagnosed epileptic patients who also have (an)other neurological disease(s). Comorbidity of epilepsy with cerebrovascular diseases, dementias, mental retardation, attention deficit and hyperactivity disorder, brain tumours, infections of the CNS, migraine, sleep disturbances (obstructive sleep apnoea syndrome), substance abuse and multiple sclerosis is discussed.

The psychosocial impact of epilepsy in older people

Given a prevalence of 0.5-1%, the epilepsies belong to the most common of neuropsychiatric diseases. Many clinicians think of the epilepsies as an entity beginning in early in life. However, the peak incidence of epilepsy in the developed world is now in the age group beyond 60 years. This population has thus an increasing importance; and in this paper we review and summarize the specific aspects of the clinical presentation, etiology, diagnosis, and treatment of older-age patients with epilepsy. In particular, we focus on the specific psychosocial impact that epilepsy has on the life of older people and their carers.