Status epilepticus secondary to glioma

Epilepsy in Patients with Gliomas

Brain tumor-related epilepsy (BTRE) is a complication that significantly impairs the quality of life and course of treatment of patients with brain tumors. Several recent studies have shed further light on the mechanisms and pathways by which genes and biological molecules in the tumor microenvironment can cause epilepsy. Moreover, epileptic seizures have been found to promote the growth of brain tumors, making the control of epilepsy a critical factor in treating brain tumors. In this study, we summarize the previous research and recent findings concerning BTRE. Expectedly, a deeper understanding of the underlying genetic and molecular mechanisms leads to safer and more effective treatments for suppressing epileptic symptoms and tumor growth.

Status epilepticus in patients with brain tumors and metastases: A multicenter cohort study of 208 patients and literature review

OBJECTIVE

Brain tumors and metastases account for approximately 10% of all status epilepticus (SE) cases. This study described the clinical characteristics, treatment, and short- and long-term outcomes of this population.

METHODS

This retrospective, multi-center cohort study analyzed all brain tumor patients treated for SE at the university hospitals of Frankfurt and Marburg between 2011 and 2017.

RESULTS

The 208 patients (mean 61.5 ± 14.7 years of age; 51% male) presented with adult-type diffuse gliomas (55.8%), metastatic entities (25.5%), intracranial extradural tumors (14.4%), or other tumors (4.3%). The radiological criteria for tumor progression were evidenced in 128 (61.5%) patients, while 57 (27.4%) were newly diagnosed with tumor at admission and 113 (54.3%) had refractory SE. The mean hospital length of stay (LOS) was 14.8 days (median 12.0, range 1-57), 171 (82.2%) patients required intensive care (mean LOS 8.9 days, median 5, range 1-46), and 44 (21.2%) were administered mechanical ventilation. All patients exhibited significant functional status decline (modified Rankin Scale) post-SE at discharge (p < 0.001). Mortality at discharge was 17.3% (n = 36), with the greatest occurring in patients with metastatic disease (26.4%, p = 0.031) and those that met the radiological criteria for tumor progression (25%, p < 0.001). Long-term mortality at one year (65.9%) was highest in those diagnosed with adult-type diffuse gliomas (68.1%) and metastatic disease (79.2%). Refractory status epilepticus cases showed lower survival rates than non-refractory SE patients (log-rank p = 0.02) and those with signs of tumor progression (log-rank p = 0.001).

CONCLUSIONS

SE occurrence contributed to a decline in functional status in all cases, regardless of tumor type, tumor progression status, and SE refractoriness, while long-term mortality was increased in those with malignant tumor entities, tumor progressions, and refractory SE. SE prevention may preserve functional status and improve survival in individuals with brain tumors.

The role of neurotransmitters in glioblastoma multiforme-associated seizures

GBM, or glioblastoma multiforme, is a brain tumor that poses a great threat to both children and adults, being the primary cause of death related to brain tumors. GBM is often associated with epilepsy, which can be debilitating. Seizures and the development of epilepsy are the primary symptoms that have a severe impact on the quality of life for GBM patients. It is increasingly apparent that the nervous system plays an essential role in the tumor microenvironment for all cancer types, including GBM. In recent years, there has been a growing understanding of how neurotransmitters control the progression of gliomas. Evidence suggests that neurotransmitters and neuromodulators found in the tumor microenvironment play crucial roles in the excitability, proliferation, quiescence, and differentiation of neurons, glial cells, and neural stem cells. The involvement of neurotransmitters appears to play a significant role in various stages of GBM. In this review, the focus is on presenting updated knowledge and emerging ideas regarding the interplay between neurotransmitters and neuromodulators, such as glutamate, GABA, norepinephrine, dopamine, serotonin, adenosine, and their relationship with GBM and the seizures induced by this condition. The review aims to explore the current understanding and provide new insights into the complex interactions between these neurotransmitters and neuromodulators in the context of GBM-related seizures.

Status epilepticus in patients with glioblastoma: Clinical characteristics, risk factors, and epileptological outcome

PURPOSE

Epilepsy is a common comorbidity in patients with glioblastoma, however, clinical data on status epilepticus (SE) in these patients is sparse. We aimed to investigate the risk factors associated with the occurrence and adverse outcomes of SE in glioblastoma patients.

METHODS

We retrospectively analysed electronic medical records of patients with de-novo glioblastoma treated at our institution between 01/2006 and 01/2020 and collected data on patient, tumour, and SE characteristics.

RESULTS

In the final cohort, 292/520 (56.2 %) patients developed seizures, with 48 (9.4 % of the entire cohort and 16.4 % of patients with epilepsy, PWE) experiencing SE at some point during the course of their disease. SE was the first symptom of the tumour in 6 cases (1.2 %) and the first manifestation of epilepsy in 18 PWE (6.2 %). Most SE episodes occurred postoperatively (n = 37, 77.1 %). SE occurrence in PWE was associated with postoperative seizures and drug-resistant epilepsy. Adverse outcome (in-house mortality or admission to palliative care, 10/48 patients, 20.8 %), was independently associated with higher status epilepticus severity score (STESS) and Charlson Comorbidity Index (CCI), but not tumour progression. 32/48 SE patients (66.7 %) were successfully treated with first- and second-line agents, while escalation to third-line agents was successful in 6 (12.5 %) cases.

CONCLUSION

Our data suggests a link between the occurrence of SE, postoperative seizures, and drug-resistant epilepsy. Despite the dismal oncological prognosis, SE was successfully treated in 79.2 % of the cases. Higher STESS and CCI were associated with adverse SE outcomes.

Seizure Management and Prophylaxis Considerations in Patients with Brain Tumors

PURPOSE OF REVIEW

The article gives an overview of the current knowledge in the management of tumor related epilepsy, including systematic reviews and consensus statements as well as recent insight into a potentially more individualized treatment approach.

RECENT FINDINGS

Tumor molecular markers as IDH1 mutation and MGMT methylation status may provide future treatment targets. Seizure control should be included as a metric in assessing efficacy of tumor treatment. Prophylactic treatment is recommended in all brain tumor patients after the first seizure. Epilepsy has a profound effect on the quality of life in this patient group. The clinician should tailor the choice of seizure prophylactic treatment to the individual patient, with the goal of limiting adverse effects, avoiding interactions and obtaining a high degree of seizure freedom. Status epilepticus is associated with inferior survival and must be treated promptly. A multidisciplinary team should treat patients with brain tumors and epilepsy.

Postoperative risk of IDH-mutant glioma-associated seizures and their potential management with IDH-mutant inhibitors

Seizures are a frequent complication of adult-type diffuse gliomas, and are often difficult to control with medications. Gliomas with mutations in isocitrate dehydrogenase 1 or 2 (IDHmut) are more likely than IDH-wild type (IDHwt) gliomas to cause seizures as part of their initial clinical presentation. However, whether IDHmut is also associated with seizures during the remaining disease course, and whether IDHmut inhibitors can reduce seizure risk, are unclear. Clinical multivariable analyses showed that preoperative seizures, glioma location, extent of resection, and glioma molecular subtype (including IDHmut status) all contributed to postoperative seizure risk in adult-type diffuse glioma patients, and that postoperative seizures were often associated with tumor recurrence. Experimentally, the metabolic product of IDHmut, d-2-hydroxyglutarate, rapidly synchronized neuronal spike firing in a seizure-like manner, but only when non-neoplastic glial cells were present. In vitro and in vivo models recapitulated IDHmut glioma-associated seizures, and IDHmut inhibitors currently being evaluated in glioma clinical trials inhibited seizures in those models, independent of their effects on glioma growth. These data show that postoperative seizure risk in adult-type diffuse gliomas varies in large part by molecular subtype, and that IDHmut inhibitors could play a key role in mitigating such risk in IDHmut glioma patients.

Tumor-associated status epilepticus: A prospective cohort in a tertiary hospital

INTRODUCTION

Tumor-associated status epilepticus (TASE) follows a relatively benign course compared with SE in the general population. Little, however, is known about associated prognostic factors.

METHODS

We conducted a prospective, observational study of all cases of TASE treated at a tertiary hospital in Barcelona, Spain between May 2011 and May 2019. We collected data on tumor and SE characteristics and baseline functional status and analyzed associations with outcomes at discharge and 1-year follow-up.

RESULTS

Eighty-two patients were studied; 58.5% (n = 48) had an aggressive tumor (glioblastoma or brain metastasis). Fifty-one patients (62.2%) had a favorable outcome at discharge compared with just 30 patients (25.8%) at 1-year follow-up. Fourteen patients (17.1%) died during hospitalization. Lateralized period discharges (LPDs) on the baseline electroencephalography (EEG), presence of metastasis, and SE severity were significantly associated with a worse outcome at discharge. The independent predictors of poor prognosis at 1-year follow-up were SE duration of at least 21 h, an aggressive brain tumor, and a nonsurgical treatment before SE onset. Lateralized period discharges, super-refractory SE, and an aggressive tumor type were independently associated with increased mortality.

CONCLUSIONS

Status epilepticus duration is the main modifiable factor associated with poor prognosis at 1-year follow-up. Accordingly, patients with TASE, like those with SE of any etiology, should receive early, aggressive treatment.

Clinical characteristics, EEG findings and implications of status epilepticus in patients with brain metastases

PURPOSE

To evaluate the clinical implications of status epilepticus in patients with metastases to the brain as well as associated demographic, clinical, EEG and radiographic features.

METHODS

Retrospective chart review of 19 patients with metastases to the brain who subsequently developed status epilepticus.

RESULTS

Of the patients who developed status epilepticus only 36.8% had a prior history of seizures since diagnosis of brain metastases. Status epilepticus most commonly occurred in the setting of a new structural injury to the brain such as new metastases, increase in size of metastases or hemorrhage. 57.9% of patients had either refractory or super-refractory status epilepticus. Focal non-convulsive status epilepticus was the most common subtype occurring in 42.1% of patients. 31.6% of patients died within 30 days of the onset of status epilepticus.

CONCLUSION

Status epilepticus eventually resolved with treatment in all patients with brain metastases; however, it is associated with poor outcomes as nearly one-third was deceased within 30-days of onset. Nevertheless, no patients died during status epilepticus. Thus, status epilepticus may be indicative of an overall poor clinical status among patients with brain metastases.

Tumor-associated status epilepticus in patients with glioma: Clinical characteristics and outcomes

Between 3 and 12% of all adult status epilepticus (SE) are caused by a brain tumor. Gliomas, and in particular, high-grade gliomas (HGGs), are at high risk of SE development. In this study, we aimed to describe the clinical characteristic and outcomes of tumor-associated SE (TASE) in a population of adult patients with glioma prospectively collected between 2013 and 2019. In the aforementioned period, we observed 26 TASE (median age: 68 years). Overall, 22 patients (85%) presented a HGG (one anaplastic astrocytoma and 21 a glioblastoma) while 4 had a LGG (two diffuse astrocytoma and two ganglioglioma). All the lesions were supratentorial, and the temporal lobe was the most frequently involved (20 patients). Fourteen patients (54%) had the SE episode as the first manifestation of the tumor; in the remaining 12 (all patients with a HGG), the development of SE heralded tumor progression or reappearance. When TASE outcomes were compared with the ones observed in the general population of SE (SEGP), the response to treatment was not different between the two populations (refractory SE (RSE)/super-refractory SE (SRSE) 12% versus 13%, p = 0.75). In the short-term, group with TASE had a significantly lower global disability (modified Rankin scale (mRS) < 3 at discharge: 60% versus 32%, p < 0.001; at 30 days follow-up: 62% versus 30%, p < 0.001) and mortality (30 days mortality: 4% versus 27%, p = 0.008). Six months and 1 year mortality did not show any difference between the two groups (6 months: 46% and 45%, respectively, p = 0.9; 1 year: 68% and 52%, respectively, p = 0.22). The appearance of TASE often heralds tumor grow and progression. Even in this context, it appears to be as treatment-responsive as SEGP and the short-term disability and mortality related to SE episode are lower than those observed in the SEGP. Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures.

Neurosurgical therapy for Status Epilepticus in Oligoastrocytoma Patient: A case report

BACKGROUND

Super refractory epilepticus status (SRSE) is a life-threatening neurologic emergency defined as 'status epilepticus (SE) that continues 24 hours or more after the onset of anaesthesia, including those cases in which the SE recurs on the reduction or withdrawal of anaesthesia', which occur in 10-15% of SE patients and rarely has been resolved surgically.

METHODS

A 20-year-old man with SRSE and a long history of left parieto-occipital oligoastrocytoma was admitted for convulsive SE that become SRSE and underwent lesionectomy guided by electrocorticography and neuro-navigation for local tumor recurrence. Histopathological diagnosis was oligoastrocytoma.

RESULTS

SRSE was aborted and the patient recovery fully without any functional deficits.

CONCLUSIONS

The lesionectomy guided by electrocorticography and neuro- navigation should be considered as a treatment option for patients with SRSE.

Brain tumor related-epilepsy

INTRODUCTION

Gliomas are commonly associated with the development of epilepsy; in some cases the two conditions share common pathogenic mechanisms and may influence each other. Brain tumor related-epilepsy (BTRE) complicates the clinical management of gliomas and can substantially affect daily life.

STATE OF THE ART

The incidence of seizures is high in patients with slow growing tumors located in the frontotemporal regions. However, recent studies suggest that epileptogenesis may be more associated with tumor molecular genetic markers than tumor grade or location. Although the exact mechanism of epileptogenesis in glioma is incompletely understood, glutamate-induced excitotoxicity and disruption of intracellular communication have garnered the most attention.

CLINICAL MANAGEMENT

Management of BTRE requires a multidisciplinary approach involving the use of antiepileptic drugs (AEDs), surgery aided by electrocorticography, and adjuvant chemoradiation.

FUTURE DIRECTIONS

Insight into the mechanisms of glioma growth and epileptogenesis is essential to identify new treatment targets and to develop effective treatment for both conditions. Selecting AEDs tailored to act against known tumor molecular markers involved in the epileptogenesis could enhance treatment value and help inform individualized medicine in BRTE.

Status Epilepticus Decreases Brain Cytochrome P450 2D4 Expression in Rats

Status epilepticus (SE) is a life-threatening neurological emergency characterized by frequent seizures. The present study aims at elucidating the effect of SE on CYP2D4 expression in the rat brain. To create a rat model of SE, Sprague-Dawley rats were intraperitoneally administered 10 mg/kg kainic acid. The CYP2D4 mRNA levels in the cortex and hippocampus of the SE rats were decreased by 0.38- and 0.39-fold, respectively. The protein level of octamer transcription factor 1 (Oct-1), which is involved in the transcriptional activation of CYP2D4 by binding to the CYP2D4 regulatory element, was also attenuated by 0.64- and 0.51-fold in these regions of the SE rat, suggesting that a reduction in Oct-1 may be involved in the CYP2D4 suppression. Yin yang 1 can function as a cofactor of histone deacetylase 1 and inhibit the binding of Oct-1 to the CYP2D4 regulatory element. The coimmunoprecipitation assay revealed that the interaction between yin yang 1 and histone deacetylase 1 in the cortex and hippocampus was enhanced during SE, indicating that this interaction is also responsible for the CYP2D4 suppression. This study clarified that SE led to a decrease in the expression of CYP2D4, thus altering the pharmacokinetics and efficacy of the drugs in the brain.