From the Guidelines
Untreated epileptic nocturnal seizures due to a brain tumor tend to increase in frequency over time, emphasizing the need for prompt management to prevent morbidity and mortality. The management of these seizures requires a dual approach addressing both the seizures and the underlying tumor. First-line treatment typically involves antiepileptic drugs (AEDs) such as levetiracetam (Keppra) starting at 500 mg twice daily, which may be titrated up to 1500 mg twice daily as needed, or lamotrigine starting at 25 mg daily and gradually increasing to 100-200 mg twice daily, as recommended by recent guidelines 1. These medications are preferred due to their favorable side effect profiles and minimal drug interactions. Concurrent neurosurgical consultation is essential to evaluate tumor resection options, as removing the epileptogenic focus can significantly reduce or eliminate seizures, as noted in studies 1. If seizures persist despite monotherapy, adjunctive AEDs like lacosamide (100-200 mg twice daily) or perampanel (4-12 mg at bedtime) may be added. Regular monitoring with serum drug levels, EEG studies, and MRI imaging is necessary to assess treatment efficacy and tumor progression, as suggested by guidelines 1. Patients should maintain a seizure diary, practice good sleep hygiene, avoid alcohol, and ensure medication adherence. This comprehensive approach is necessary because brain tumors disrupt normal neuronal activity through various mechanisms including mass effect, peritumoral edema, and altered neurotransmitter function, creating hyperexcitable neural networks that trigger seizures, particularly during sleep state transitions. Key considerations in the management include:
- The choice of AEDs, with levetiracetam being a preferred option due to its efficacy and tolerability 1
- The importance of neurosurgical evaluation for potential tumor resection 1
- The need for regular monitoring and adjustment of treatment as necessary 1
- Patient education on seizure management and lifestyle modifications to reduce seizure risk. Given the complexity of managing brain tumor-related seizures, a multidisciplinary approach involving neurology, neurosurgery, and oncology is crucial for optimizing patient outcomes, as emphasized by recent clinical guidelines 1.
From the Research
Management Approach for Untreated Epileptic Nocturnal Seizures due to Brain Tumor
- The management of epileptic nocturnal seizures due to brain tumor typically involves treatment with antiepileptic drugs (AEDs) to prevent recurrence 2.
- Strong clinical data exists to discourage routine prophylaxis in patients who have not had seizures, but AED treatment should be initiated after a first seizure has occurred 3.
- The newer AEDs, such as levetiracetam, lamotrigine, lacosamide, topiramate, or pregabalin, are preferable due to their side-effect profile and limited interactions with other drugs 2.
Seizure Frequency Over Time
- There is limited direct evidence on whether untreated epileptic nocturnal seizures due to brain tumor tend to increase in frequency over time.
- However, studies suggest that seizures in brain tumor patients can be difficult to control and may require additional anticonvulsants if they persist despite initiation of an appropriate monotherapy 2, 4.
- Levetiracetam has been shown to be effective in reducing seizure frequency in brain tumor patients, with some studies reporting a decrease in seizure frequency and others reporting an improvement in seizure control 4, 5, 6.
Treatment Options
- Levetiracetam is often considered a first-line agent for reducing seizures in patients with brain tumors due to its favorable efficacy and safety profile 5, 6.
- Other potential add-on AEDs in case of uncontrolled seizures include lacosamide, perampanel, and valproic acid 3.
- Early surgical intervention may also improve seizure outcomes in individuals with medically refractory epilepsy, especially in patients with a single lesion that is epileptogenic 2.