The role of levetiracetam in treatment of seizures in brain tumor patients

Duration of Prophylactic Levetiracetam After Surgery for Brain Tumor: A Prospective Randomized Trial

BACKGROUND

Levetiracetam is commonly used as a prophylactic antiseizure medication in patients undergoing surgical resection of brain tumors.

OBJECTIVE

To quantitate side effects experienced in patients treated with 1 week vs 6 weeks of prophylactic levetiracetam using validated measures for neurotoxicity and depression.

METHODS

Patients undergoing surgical resection of a supratentorial tumor with no seizure history were randomized within 48 hours of surgery to receive prophylactic levetiracetam for the duration of either 1 or 6 weeks. Patients were given oral levetiracetam extended release 1000 mg during the first part of this study. Owing to drug backorder, patients enrolled later in this study received levetiracetam 500 mg BID. The primary outcome was the change in the neurotoxicity score 6 weeks after drug initiation. The secondary outcome was seizure incidence.

RESULTS

A total of 81 patients were enrolled and randomized to 1 week (40 patients) or 6 weeks (41 patients) of prophylactic levetiracetam treatment. The neurotoxicity score slightly improved in the overall cohort between baseline and reassessment. There was no significant difference between groups in neurotoxicity or depression scores. Seizure incidence was low in the entire cohort of patients with 1 patient in each arm experiencing a seizure during the follow-up period.

CONCLUSION

The use of prophylactic levetiracetam did not result in significant neurotoxicity or depression when given for either 1 week or 6 weeks. The incidence of seizure after craniotomy for tumor resection is low regardless of duration of therapy.

Impact of seizures and antiseizure medication on survival in patients with glioma

PURPOSE

Seizures are a common presenting symptom among patients with low- and high-grade glioma. However, the impact and inter-relationship between the presence of seizures, anti-seizure medication (ASM) and survival are unclear. We retrospectively analyzed the incidence of seizures and identified the pattern and relationship of anti-seizure medication on survival in our cohort of patients with glioma.

METHODS

We evaluated all glioma patients who underwent treatment at the University of Malaya Medical Centre (UMMC) between 2008 and 2020. Demographic and clinical data of seizures and pattern of ASM administration in comparison to overall survival were analyzed.

RESULTS

A total of 235 patients were studied, with a minimum of one year clinical follow-up post-treatment. The median survival for low-grade glioma was 38 months whereas high-grade glioma was 15 months. One-third of our glioma patients (n = 74) presented with seizures. All patients with seizures and a further 31% of patients without seizures were started on anti-seizure medication preoperatively. Seizure and Levetiracetam (LEV) were significantly associated with OS on univariate analysis. However, only LEV (HR 0.49; 95% CI 0.23-0.87; p=0.02) was significantly associated with improving overall survival (OS) on multivariate analysis. Once ASM was adjusted for relevant factors and each other, LEV was associated with improved survival in all grade gliomas (HR 0.52; 95% CI 0.31-0.88; p=0.02) and specifically high-grade gliomas (HR 0.53; 95% CI 0.30-0.94; p=0.03).

CONCLUSIONS

Pre-operative seizures among patients with glioma indicated a better overall prognosis. The administration of ASM, specifically LEV was associated with a  significant survival advantage in our retrospective cohort of patients.

To Analyze the Application Value of Perioperative Nursing Care in Patients with Resected Brain Tumor Accompanied with Epileptic Symptoms under Cortical Electrocorticography Monitoring

Objective. To explore the application value of perioperative nursing for patients with brain tumors with epilepsy symptoms under the cortical electrocorticography (EEG) monitoring. Methods. A total of 86 patients with brain tumor complicated with epilepsy admitted to the department of brain surgery of our hospital from January 2018 to December 2019 were selected as the research objects, and all underwent resection under cortical EEG monitoring. According to different nursing methods, they were divided into the control group and observation group, each with 43 cases. The control group was given perioperative basic nursing, and the observation group was given perioperative comprehensive nursing. The EEG image of the patient during the operation was observed by a portable EEG monitor. Anxiety and depression were assessed by self-rating anxiety scale (SAS) and self-rating depression scale (SDS) scores. The self-made satisfaction questionnaire was used to investigate the nursing satisfaction. A visual analogue (VAS) score is used to assess pain degree. A multiparameter monitor was used to detect the patient’s heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP). The quality of life was assessed by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-30). The complication rate and recurrence rate were also counted. Results. Eighty-six patients with epileptic brain tumor developed spikes in 35 cases, including 7 meningiomas, 22 gliomas, and 6 cholesteatomas; 27 cases of sharp waves, including 14 meningiomas, 12 gliomas, and 1 case of cholesteatomas; and 24 cases of complex wave, including 9 cases of meningioma, 13 cases of glioma, and 2 cases of cholesteatoma. There was no significant difference in the scores of SAS, SDS, VAS, HR, SBP, DBP, and quality of life between the two groups at T0. The VAS score increased at T1 and T2, and the increase in the control group was greater than that in the observation group. At T3 and T4, the SAS, SDS, and VAS scores of the two groups decreased, and the observation group decreased more than the control group. HR, SBP, and DBP of the two groups showed an upward trend at T1 and T2, and the increase in the control group was more significant than that in the observation group. At T3, the three indicators of the two groups decreased, and the observation group decreased more significantly than the control group. At T4, the scores of all indicators of the quality of life of the two groups increased, and the observation group increased more significantly than the control group. The nursing satisfaction of the observation group was higher than that of the control group. The complication rate and recurrence rate in the observation group were decreased compared with the control group. Conclusion. Perioperative comprehensive nursing intervention for patients with epileptic brain tumor undergoing resection under cortical EEG monitoring can reduce or even eliminate the recurrence rate of epilepsy, reduce the patient’s pain and stress response, and improve the patient’s quality of life. It can also reduce the occurrence of complications, improve nursing satisfaction, thereby improving patient compliance, and has a high clinical application value.

Xanthotoxin enhances the anticonvulsant potency of levetiracetam and valproate in the 6-Hz corneal stimulation model in mice

Xanthotoxin (8-methoxypsoralen; XANT) is a furanocoumarin that has many biological properties, including antiepileptic activity. This study evaluated the effect of XANT on the ability of classical and novel antiepileptic drugs to prevent seizures evoked by the 6-Hz corneal stimulation-induced seizure model, which is thought to be an experimental model of psychomotor (limbic) seizures in humans. XANT (50 mg/kg, administered i.p.) significantly potentiated the anticonvulsant activity of levetiracetam and valproate, decreasing their median effective dose (ED₅₀ ) values from 19.37 to 2.83 mg/kg (P < 0.01) for levetiracetam and from 92.89 to 44.44 mg/kg (P < 0.05) for valproate. Neither XANT (50 mg/kg) alone nor its combination with the anticonvulsant drugs (at their ED₅₀ values from the 6-Hz test) affected motor coordination; skeletal muscular strength and long-term memory, as determined in the chimney; and grip strength and passive avoidance tests, respectively. Measurement of total brain antiepileptic drug concentrations revealed that XANT (50 mg/kg) had no impact on levetiracetam total brain concentrations, indicating the pharmacodynamic nature of interaction between these antiepileptic drugs in the mouse 6-Hz model. However, XANT (50 mg/kg, i.p.) significantly increased total brain concentrations of valproate (P < 0.01), indicating the pharmacokinetic nature of interactions between drugs. XANT in combination with levetiracetam exerts beneficial anticonvulsant pharmacodynamic interactions in the 6-Hz mouse psychomotor seizure model.

Lack of drug interaction between levetiracetam and high-dose methotrexate in patients with lymphoma

STUDY OBJECTIVE

To determine whether there is a drug-drug interaction precluding the concomitant use of levetiracetam and high-dose methotrexate (HDMTX).

DESIGN

Retrospective analysis.

SETTING

Large academic tertiary care medical center.

PATIENTS

Adult lymphoma patients who received HDMTX as a 4-h infusion with or without concomitant levetiracetam.

MEASUREMENTS AND MAIN RESULTS

Generalized estimating equations clustered on patient were used to assess each outcome. The primary outcome was the incidence of delayed MTX elimination (MTX level >1 µmol/L at 48 h). Secondary outcomes included incidence of acute kidney injury (AKI) and hospital length of stay (LOS). The 430 included patients receiving 1993 doses of HDMTX had a median (IQR) age of 66 (57.5, 72.6) years, 88 (20.5%) received concomitant levetiracetam with at least one dose of MTX, 267 (62.1%) were male, and 397 (92.3%) were Caucasian. HDMTX doses ranged from 1 to 8 g/m² . The most common lymphoma diagnoses were systemic diffuse large B-cell lymphoma (DLBCL; 58.5%) and systemic DLBCL with central nervous system (CNS) involvement (32.8%). Rates of delayed elimination with and without levetiracetam were 13.4% and 16.3%, respectively (OR = 0.80, 95% CI 0.47-1.34, p = 0.39). AKI occurred in 15.6% and 17.0% of patients with and without concomitant levetiracetam, respectively (OR = 0.83, 95% CI 0.52-1.33, p = 0.28). The median LOS with and without levetiracetam was 4.2 and 4.1 days, respectively (p = 0.039). On multivariable analyses, only age, body surface area, diagnosis of systemic DLBCL with CNS involvement, serum creatinine, hemoglobin, total bilirubin, and dose of HDMTX were associated with delayed elimination.

CONCLUSIONS

High-dose methotrexate administered with concomitant levetiracetam was not associated with increased risk for delayed MTX elimination or AKI. These results support that levetiracetam and HDMTX are safe for coadministration.

Levetiracetam at the End of Life: A Case Report and Discussion

Patients with primary brain tumors may present with neuropsychiatric symptoms such as behavioral and personality changes at any point during the disease course. Symptoms may be due to tumor treatment, the disease itself, or due to therapy for symptoms such as seizures. Levetiracetam is an attractive choice of antiepileptic medication because of relatively fewer drug interactions and may be administered through the subcutaneous route. Aggressive behavior in advanced brain tumors can have a profound negative impact on patients and their families and carers, particularly when deteriorating toward death. We report a case of neuropsychiatric symptoms in progressive glioblastoma multiforme while on stable levetiracetam doses, which improved with reduction and cessation of the drug. We review the existing literature on seizures in primary brain tumors, their antiepileptic drug management, and the risk of consequent neuropsychiatric adverse events.

Efficacy of perioperative anticonvulsant prophylaxis in seizure-naïve glioma patients: A meta-analysis

The efficacy of perioperative seizure prophylaxis in seizure-naïve glioma patients is still controversial. Thus we conducted this meta-analysis to assess the effectiveness of perioperative prophylactic antiepileptic drugs (AEDs) on postoperative seizures in seizure-naïve glioma for the first time. We systematically searched PubMed, Embase, Weipu (VIP) and Chinese National Knowledge Infrastructure (CNKI) until July 5, 2019 for eligible studies. Fixed or random model was used to calculate the odds ratios in STATA 12.0 software. Subgroup analyses of early postoperative seizure, late postoperative seizure, high-grade glioma (WHOIII-IV) and phenytoin (PHT) or phenobarbital (PB) prophylaxis were conducted. Altogether 1143 seizure-naïve glioma patients from 9 studies were included in this meta-analysis, containing 643 prophylaxed and 503 non-prophylaxed patients. No significant association was detected between perioperative seizure prophylaxis and postoperative seizure occurrence in glioma patients without preoperative seizure history (OR = 0.91, 95% CI = 0.65-1.26, P = 0.56). Perioperative AED prophylaxis showed no significant benefit to postoperative seizures when stratified by early postoperative seizure(within the first postoperative week), late postoperative seizure (after the first postoperative week), high-grade glioma and PHT or PB prophylaxis (all P > 0.05). Current evidence indicated that perioperative seizure prophylaxis did not reduce the occurrence of postoperative seizure in seizure-naïve glioma patients. The pros and cons of perioperative seizure prophylaxis should be considered before the start of perioperative AEDs treatment.

Palliative Care for Children with Central Nervous System Malignancies

Children with central nervous system (CNS) malignancies often suffer from high symptom burden and risk of death. Pediatric palliative care is a medical specialty, provided by an interdisciplinary team, which focuses on enhancing quality of life and minimizing suffering for children with life-threatening or life-limiting disease, and their families. Primary palliative care skills, which include basic symptom management, facilitation of goals-of-care discussions, and transition to hospice, can and should be developed by all providers of neuro-oncology care. This chapter will review the fundamentals of providing primary pediatric palliative care.

Prevention and management of postoperative seizures in neuro-oncology

INTRODUCTION

Epilepsy related to brain tumors is often difficult to treat and may impact the quality of life. We performed a review of current recommendations for the prevention of postoperative seizures and optimizing the anti-epileptic treatment.

MATERIAL AND METHODS

Based on studies performed since 2000 we conducted the review by (1) analyzing the incidence of tumoral epilepsy and mechanisms of epileptogenicity; (2) describing the current medical and surgical strategy according to oncologic treatments; (3) discussing the management of postoperative seizures; (4) considering the drug withdrawal after oncologic therapy.

RESULTS

Epilepsy related to supra-tentorial brain tumors is frequent (40-60%) especially in low-grade gliomas, glioneuronal tumors, fronto-temporal and eloquent cortex locations. Seizures can occur as a presenting symptom or during the course of the tumor, including after surgery and oncological treatments. Maximal safe surgical resection is the more effective therapy, alone or combined with adjuvant therapy (chemotherapy, radiotherapy). Anti-epileptic drugs are not indicated for epilepsy prophylaxis in patients without seizures but only after the first seizure due to high risk of recurrence. As they may generate adverse effects and interfere with oncological treatments, the choice is based on efficacy, tolerability and potential interactions. New anti-epileptic non-enzyme-inducing drugs are recommended in first-line monotherapy in association with adjuvant oncological therapies. Enzyme-inhibiting drugs could have a favorable effect on survival. Late seizures are often related to tumor progression or recurrence. Discontinuation of anti-epileptic drugs could be considered after successful oncological treatment and a stable medical condition.

CONCLUSION

These guidelines are helpful for a rational therapy in tumoral epilepsy.

Acute liver injury induced by levetiracetam and temozolomide co-treatment

BACKGROUND

Temozolomide (TMZ) is an alkylating agent used for treatment of brain neoplasms and levetiracetam (LEV) is a commonly used antiepileptic. When administered separately each medication has few negative side effects impacting the liver.

AIMS

We sought to determine the risk of liver injury associated with the co-administration of TMZ and LEV.

METHODS

A case-control study was performed comparing patients who received combination therapy of TMZ and LEV (group A) with matched controls (group B) who received monotherapy with one of either TMZ or LEV. We assessed patient demographics, laboratory results including presence of liver injury, and mortality.

RESULTS

Twenty-six patients were included in group A and 68 patients were included in group B. Both groups were similar with respect to demographics and baseline liver function tests (P>0.05). There was a significant elevation in liver enzymes in 73%, 46%, 19%, 31% and 27% of ALT, AST, ALK-P, GGT and bilirubin, respectively, in group A, as compared to elevations of 10.3%, 19%, 1.5%, 7% and 1.5%, respectively in group B (P<0.05). One patient in group A died as a result of acute liver failure while no deaths from acute liver failure occurred in group B (P=0.05). Univariate analysis identified combination therapy as a risk factor for liver injury. Multivariate regression showed that only co-treatment with TMZ and LEV was an independent risk factor for liver injury with an odds ratio of 19.1 (95 CI, 2.16-160).

CONCLUSIONS

Combination therapy with TMZ and LEV may precipitate acute liver injury and even death.

The variability of motor evoked potential latencies in neurosurgical motor mapping by preoperative navigated transcranial magnetic stimulation

Background

Recording of motor evoked potentials (MEPs) is used during navigated transcranial magnetic stimulation (nTMS) motor mapping to locate motor function in the human brain. However, factors potentially underlying MEP latency variability in neurosurgical motor mapping are vastly unknown. In the context of this study, one hundred brain tumor patients underwent preoperative nTMS-based motor mapping of the tumor hemisphere between 2010 and 2013. Fourteen predefined predictor variables were recorded, and MEP latencies of abductor pollicis brevis muscle (APB), abductor digiti minimi muscle (ADM), and flexor carpi radialis muscle (FCR) were analyzed using linear mixed-effect multiple regression analysis with the forward step-wise model comparison approach.

Results

Common factors (relevant to APB, ADM, and FCR) for MEP latency variability were gender, most likely due to body height, and antiepileptic drug (AED) intake. Muscle-specific factors (relevant to APB, ADM, or FCR) for MEP latency variability were resting motor threshold (rMT), tumor side, and tumor location.

Conclusions

Based on a large cohort of neurosurgical patients, this study provides data on a wide range of clinical factors that may underlie MEP latency variability. The factors that significantly contributed to MEP latency variability should be standardly recorded and taken into consideration during neurosurgical motor mapping.

Clinical Factors Underlying the Inter-individual Variability of the Resting Motor Threshold in Navigated Transcranial Magnetic Stimulation Motor Mapping

Correctly determining individual's resting motor threshold (rMT) is crucial for accurate and reliable mapping by navigated transcranial magnetic stimulation (nTMS), which is especially true for preoperative motor mapping in brain tumor patients. However, systematic data analysis on clinical factors underlying inter-individual rMT variability in neurosurgical motor mapping is sparse. The present study examined 14 preselected clinical factors that may underlie inter-individual rMT variability by performing multiple regression analysis (backward, followed by forward model comparisons) on the nTMS motor mapping data of 100 brain tumor patients. Data were collected from preoperative motor mapping of abductor pollicis brevis (APB), abductor digiti minimi (ADM), and flexor carpi radialis (FCR) muscle representations among these patients. While edema and age at exam in the ADM model only jointly reduced the unexplained variance significantly, the other factors kept in the ADM model (gender, antiepileptic drug intake, and motor deficit) and each of the factors kept in the APB and FCR models independently significantly reduced the unexplained variance. Hence, several clinical parameters contribute to inter-individual rMT variability and should be taken into account during initial and follow-up motor mappings. Thus, the present study adds basic evidence on inter-individual rMT variability, whereby some of the parameters are specific to brain tumor patients.

Abbreviated levetiracetam treatment effects on behavioural and histological outcomes after experimental TBI

OBJECTIVE

Long-term prophylactic treatment with levetiracetam (LEV) has multiple neuroprotective effects in a traumatic brain injury (TBI) rat model. Although a rational time-frame of seizure prophylactic treatment with LEV for after TBI is not well established, clinical prophylaxis with LEV often includes treatment duration similar to clinical treatment guidelines with Phenytoin. Thus, this study investigated the effects of abbreviated LEV treatment on behavioural function and histological evidence of neuroprotection.

RESEARCH DESIGN

Pre-clinical trial of abbreviated LEV dosing in an experimental model of TBI Methods: After either controlled cortical impact (CCI) injury or sham surgery, rats received three 50 mg kg(-1) doses over 24 hours or vehicle. After injury/sham surgery, beam performance, spatial learning, contusion volume size and hippocampal neuron survival were assessed.

RESULTS

Abbreviated LEV did not improve motor or cognitive performance after TBI. Further, abbreviated LEV did not improve hippocampal neuron sparing or contusion volumes compared with vehicle controls.

CONCLUSIONS

Together with previous work assessing daily LEV treatment, these results suggest that longer-term therapy may be required to confer beneficial effects within these domains. These findings may guide (1) future experimental studies assessing minimal effective dosing for neuroprotection and anti-epileptogenesis and (2) treatment guideline updates for seizure prophylaxis post-TBI.

Efficacy and safety of prophylactic levetiracetam in supratentorial brain tumour surgery: a systematic review and meta-analysis

AIMS

The aim of this study was to perform an up-to-date systematic review and meta-analysis on the efficacy and safety of prophylactic administration of levetiracetam in brain tumour patients.

METHOD

A systematic review of studies published until April 2015 was conducted using Scopus/Elsevier, EMBASE and MEDLINE. The search was limited to articles reporting results from adult patients, suffering from brain tumour, undergoing supratentorial craniotomy for tumour resection or biopsy and administered levetiracetam in the perioperative period for seizure prophylaxis. Outcomes included the efficacy and safety of levetiracetam, as well as the tolerability of the specific regimen, defined by the discontinuation of the treatment due to side effects.

RESULTS

The systematic review included 1148 patients from 12 studies comparing levetiracetam with no treatment, phenytoin and valproate, while only 243 patients from three studies, comparing levetiracetam vs phenytoin efficacy and safety, were included in the meta-analysis. The combined results from the meta-analysis showed that levetiracetam administration was followed by significantly fewer seizures than treatment with phenytoin (OR = 0.12 [0.03-0.42]: χ(2) = 1.76: I(2) = 0%). Analysis also showed significantly fewer side effects in patients receiving levetiracetam, compared to other groups (P < 0.05). The combined results showed fewer side effects in the levetiracetam group compared to the phenytoin group (OR = 0.65 [0.14-2.99]: χ(2) = 8.79: I(2) = 77%).

CONCLUSIONS

The efficacy of prophylaxis with levetiracetam seems to be superior to that with phenytoin and valproate administration. Moreover, levetiracetam use demonstrates fewer side effects in brain tumour patients. Nevertheless, high risk of bias and moderate methodological quality must be taken into account when considering these results.

Collaboration in the presence of cerebral edema: The complications of steroids

BACKGROUND

Brain tumor patients often present with neurological changes in the presence of cerebral edema. High-dose dexamethasone is often required for symptom management in brain tumor patients. There are limitations in the foundational research that support the recommendations for appropriate prescribing of dexamethasone. Understanding these limitations can help prescribers and care teams collaborate to better manage this unique patient population as well as identify areas for further research.

METHODS

Evidence-based clinical practice guidelines for the management of adult brain tumor patients were reviewed from several certifying organizations. A complex database search and literature review was completed regarding relevant evidence used within these guidelines and for any supporting literature. The search was limited to MEDLINE, Cumulative Index to Nursing and Allied Health, Cochrane Library, and the National Guideline Clearinghouse using keywords. Each selected evidence-based guideline underwent appraisal using the Johns Hopkins Evidence-based Practice Model.

RESULTS

All clinical practice guidelines identified recommendations for appropriate dosing and tapering of dexamethasone. The management of steroid-induced side effects was addressed in two of the reviewed guidelines. Only one guideline identified specific nursing interventions for monitoring steroid-related side effects. No guideline addressed interval timing of provider or nursing-based interventions as well as the role of collaboration between provider and nurse in monitoring for steroid toxicities.

CONCLUSIONS

More high-quality, well-controlled studies are needed around dexamethasone dosing for the management of cerebral edema. Clinical practice guidelines need to encompass both the prescriber and nursing-based interventions. Collaboration between disciplines is a necessity when monitoring and managing steroid-induced toxicities in brain tumor patients. Future evidence-based guidelines need recommendations for appropriate interval screening tests and quantifiable tools needed to aid in monitoring steroid-induced complications.

Sudden Death Due to Vestibular Schwannoma: Caution in Emergent Management

OBJECTIVE

To enhance understanding of the possible dangers of large vestibular schwannomas and their potential to cause sudden death through rare situations such as brain herniation precipitated by cerebrospinal fluid pressure shifts.

PATIENT

An otherwise healthy 32-year-old woman with a magnetic resonance imaging demonstrating a cystic cerebellopontine angle mass, presumptive for vestibular schwannoma, experienced sudden onset of headaches, nausea, and vomiting.

INTERVENTION

The patient was admitted to the intensive care unit, started on anticonvulsants, investigated with serial computed tomography (CT) scans, and then elective intubation and ventriculostomy when her condition worsened.

MAIN OUTCOME MEASURE(S)

Clinical and radiological findings, as well as outcome of interventions.

RESULTS

In the first hours of admission, the patient underwent serial CT scans that demonstrated fourth ventricle compression and hydrocephalus. When the patient's condition worsened, elective intubation was undertaken and an external ventricular drain was inserted. Very high intracranial pressures were noted despite cerebrospinal fluid drainage. Postoperative CT and magnetic resonance imaging demonstrated ascending transtentorial and tonsillar herniation as well as scattered cortical infarcts. Brain death was determined and care was withdrawn 5 days later.

CONCLUSION

This is a very rare patient report of sudden death caused by a large vestibular schwannoma despite assertive emergent management. There was no intratumoral or intracranial haemorrhage. Brain death was likely a result of ascending transtentorial herniation that can occur with large posterior fossa tumors and be exacerbated by cerebrospinal fluid shifts after ventriculostomy.

Haematological toxicity of Valproic acid compared to Levetiracetam in patients with glioblastoma multiforme undergoing concomitant radio-chemotherapy: a retrospective cohort study

Patients with glioblastoma multiforme (GBM) and symptomatic seizures are in need of a sufficient antiepileptic treatment. Haematological toxicity is a limiting side effect of both, first line radio-chemotherapy with temozolomide (TMZ) and co-medication with antiepileptic drugs. Valproic acid (VPA) and levetiracetam (LEV) are considered favourable agents in brain tumor patients with seizures, but are commonly reported to induce haematological side effects on their own. We hypothesized, that antiepileptic treatment with these agents has no increased impact on haematological side effects during radio-chemotherapy in the first line setting. We included 104 patients from two neuro-oncologic centres with GBM and standard radio-chemotherapy in a retrospective cohort study. Patients were divided according to their antiepileptic treatment with either VPA, LEV or without antiepileptic drug therapy (control group). Declines in haemoglobin levels and absolute blood cell counts for neutrophil granulocytes, lymphocytes and thrombocytes were analyzed twice during concomitant and once during adjuvant phase. A comparison between the examined groups was performed, using a linear mixed model. Neutrophil granulocytes, lymphocytes and thrombocytes significantly decreased over time in all three groups (all p < 0.012), but there was no significant difference between the compared groups. A significant decline in haemoglobin was observed in the LEV treated group (p = 0.044), but did not differ between the compared groups. As a novel finding, this study demonstrates that co-medication either with VPA or LEV in GBM patients undergoing first line radio-chemotherapy with TMZ has no additional impact on medium-term haematological toxicity.

Peritumoral epilepsy: relating form and function for surgical success

Seizures are a prominent symptom in patients with both primary and secondary brain tumors. Medical management of seizure control in this patient group is problematic as the mechanisms linking tumorigenesis and epileptogenesis are poorly understood. It is possible that several mechanisms contribute to tumor-associated epileptic zone formation. In this review, we discuss key candidates that may be implicated in peritumoral epileptogenesis and, in so doing, hope to highlight areas for future research. Furthermore, we summarize the current role of antiepileptic medications in this type of epilepsy and examine the changes in surgical practice which may lead to improved seizure rates after tumor surgery. Lastly, we speculate on possible future preoperative and intraoperative considerations for improving seizure control after tumor resection.