Risk factors and control of seizures in 778 Chinese patients undergoing initial resection of supratentorial meningiomas

Meningiomas-Related Epilepsy After Surgery

BACKGROUND

Meningioma-related epilepsy (MRE) is observed in approximately 30% of patients. Although studies focus on identifying risk factors related to pre- and postoperative MRE, there is no clear evidence regarding the timing for discontinuing antiseizure medications (ASMs) after surgical resection.

METHODS

We retrospectively collected data from a series of naïve supratentorial meningiomas treated with surgical resection. Preoperative MRI was used to calculate the meningioma and peritumoral edema (PE) volumes through a voxel-based system. We analyzed the frequency of pre- and postoperative epilepsy in the group of meningiomas with and without perilesional edema (with PE > 1 cm3 as the cut-off).

RESULTS

From a clinical series of 507 patients, we included 128 who underwent surgical resection in our center between January 2020 and December 2022, with a mean follow-up of 30.1 ± 19.8 months. Surgical treatment had a curative effect on MRE (41.4% preoperative vs. 19.5% postoperative; p = 0.0001). We observed a statistically significant reduction in the seizure rate in cases with preoperative PE (45.3% preoperative vs. 18.9% postoperative; p = 0.0002) and a non-statistically significant reduction in cases without PE (32.5% preoperative vs. 21.4% postoperative; p = 0.24). We observed ASM continuation in 37.8% of Engel IA patients.

CONCLUSIONS

PE increases the likelihood of MRE resolution with surgery. Our results show that surgical resection directly impacts MRE and ASM discontinuation in the presence of preoperative PE. The PE is a reassuring factor in decision-making regarding the timing of ASM discontinuation after surgery.

Oedema as a prognostic factor for seizures in meningioma - a systematic review and meta-analysis

Meningiomas are benign intracranial tumours that commonly lead to seizures and oedema. An understanding of seizure risk factors is essential for the meningioma community. Many studies have differing conclusions on whether oedema is associated with seizure. Existing meta-analyses are limited by lack of focus on oedema. Our objective was to summarise all literature on oedema as a prognostic factor for seizures in meningioma patients. We searched OVID, Scopus, Pubmed, Web of Science, ClinicalTrials.gov and Google scholar up to April 2024 for reports with more than 10 human meningioma participants. Statistics were performed on R-Studio. Cochrane and Campbell guides for systematic reviews and meta-analysis were followed. Risk of bias was assessed with ROBINS-E. Our protocol was uploaded to INPLASY. We included 51 studies for meta-analysis and 21 for narrative review. Most studies were of surgically treated adults. Heterogeneity was low once outliers were removed. Preoperative oedema was associated with preoperative seizure (k = 28, n = 7,725, OR 3.5, 95% CI = 3.1-4.0, I2 = 0%, p < .001), early postoperative seizure (k = 9, n = 2,929, OR 1.5, CI = 1.1-1.9, I2 = 0%, p = .011) and late postoperative seizure (k = 9, n = 2,150, OR 1.9, CI = 1.5-2.2, I2 = 0%, p < .001). We performed an additional adjusted analysis for preoperative seizures which was also significant (k = 3, n = 2,241, OR 3.9, CI = 2.4-6.3, I2 = 0%, p = .007). There were few studies of post-radiosurgery oedema and seizure, and of postoperative oedema and seizure, with insignificant but positive associations. Preoperative oedema is a key factor for preoperative seizures. Oedema also increases risk of postoperative seizures. Further study in conservative, radiosurgery and paediatric populations, as well as study of oedema and seizure severity or subtype is warranted.

Predictors for the Occurrence of Seizures in Meningioma

Seizure is a common symptom of meningioma that has a major impact on patients' quality of life. The purpose of this study was to identify predictive factors for the occurrence of preoperative and postoperative seizures. The data of patients with resection of histologically confirmed meningioma at University Hospital Leipzig from 2009 to 2018 were retrospectively examined. Univariate and multivariate logistic regression analyses of different factors influencing seizure outcome were performed. The male gender was identified as an independent positive predictor for preoperative seizures (odds ratio [OR] 1.917 [95% confidence interval {CI} 1.044-3.521], p = 0.036), whereas headache (OR 0.230 [95% CI 0.091-0.582], p = 0.002) and neurological deficits (OR 0.223; [95% CI 0.121-0.410], p < 0.001) were demonstrated to be negative predictive factors. Sensorimotor deficit after surgery (OR 4.490 [95% CI 2.231-9.037], p < 0.001) was found to be a positive predictor for the occurrence of postoperative seizures. The identified predictors for the occurrence of seizures in meningioma can contribute to improving seizure treatment and patients' quality of life.

Predictors of early and late postoperative seizures in meningioma patients: a systematic review and meta-analysis

Meningioma is the most common type of primary brain tumor which presents with a variety of neurological manifestations. Surgical resection tends to be the preferred treatment. The occurrence of seizures after resection is common, which occur either early, within seven days of operation, or late. Our meta-analysis investigated the possible predictors of early and late postoperative seizures. We assessed the relevant observational studies on predictors of postoperative seizures published in PubMed, Scopus, and Web of Science from January 2000 to September 2022, and those that met inclusion criteria were included. We calculated the association between potential predicting factors and postoperative seizures, odds ratios (ORs) with 95% confidence intervals (CIs) applying either random or fixed-effect models. The early and late postoperative seizures were evaluated individually. Thirteen observational studies involving 4176 patients were included. Seizures occurred in 250 (6%) and 584 (14%) patients, respectively, in the early and late postoperative phases. Shared predictors for early and late seizures included tumors involving the motor cortex (OR = 2.7; 95% CI: 1.67-4.38, OR = 2.46; 95% CI: 1.68-3.61), postoperative neurological deficit (OR = 4.68; 95% CI: 2.67-8.22, OR = 2.01; 95% CI: 1.39-2.92), and preoperative seizures (OR = 2.52; 95% CI: 1.82-3.49, OR = 4.35; 95% CI: 3.29-5.75). Peritumoral edema (OR = 1.99; 95% CI: 1.49-2.64) was a significant factor only among late postoperative seizure patients while surgical complications (OR = 3.77; 95% CI: 2.39-5.93) was a significant factor solely for early postoperative seizures. Meningioma patients commonly experience early and late postoperative seizures. Identifying predictors of postoperative seizures is essential to diagnose and manage them effectively.

Intravenous tranexamic acid for intracerebral meningioma resections: A randomized, parallel-group, non-inferiority trial

STUDY OBJECTIVES

Tranexamic acid (TXA) is an antifibrinolytic that is widely used to reduce surgical bleeding. However, TXA occasionally causes seizures and the risk might be especially great after neurosurgery. We therefore tested the hypothesis that TXA does not meaningfully increase the risk of postoperative seizures within 7 days after intracranial tumor resections.

DESIGN

Randomized, double-blind, placebo-controlled, non-inferiority trial.

SETTING

Beijing Tiantan Hospital, Capital Medical University.

PATIENTS

600 patients undergoing supratentorial meningioma resection were included from October 2020 to August 2022.

INTERVENTIONS

Patients were randomly assigned to a single dose of 20 mg/kg of TXA after induction (n = 300) or to the same volume of normal saline (n = 300).

MEASUREMENT

The primary outcome was postoperative seizures occurring within 7 days after surgery, analyzed in both the intention-to-treat and per-protocol populations. Non-inferiority was defined by an upper limit of the 95% confidence interval for the absolute difference being <5.5%. Secondary outcomes included incidence of non-epileptic complication within 7 days, changes in hemoglobin concentration, estimated intraoperative blood loss. Post hoc analyses included the types and timing of seizures, oozing assessment, and a sensitivity analysis for the primary outcome in patients with pathologic diagnosis of meningioma.

MAIN RESULTS

All 600 enrolled patients adhered to the protocol and completed the follow-up for the primary outcome. Postoperative seizures occurred in 11 of 300 (3.7%) of patients randomized to normal saline and 13 of 300 (4.3%) patients assigned to tranexamic acid (mean risk difference, 0.7%; 1-sided 97.5% CI, -∞ to 4.3%; P = 0.001 for noninferiority). No significant differences were observed in any secondary outcome. Post hoc analysis indicated similar amounts of oozing, calculated blood loss, recurrent seizures, and timing of seizures.

CONCLUSION

Among patients having supratentorial meningioma resection, a single intraoperative dose of TXA did not significantly reduce bleeding and was non-inferior with respect to postoperative seizures after surgery.

REGISTRY INFORMATION

This trial was registered at clinicaltrials.gov (NCT04595786) on October 22, 2020, by Dr.Yuming Peng.

Case Report: "Aggressive" perioperative antiseizure medication prophylaxis in patients with glioma-related epilepsy at high risk of early postoperative seizures following awake craniotomy

Early postoperative seizures (EPS) are a common complication of brain tumor surgery. EPS can lead to hemorrhage, cerebral hypoxia, increased intracranial pressure, longer hospitalization, reduced quality of life, decreased overall survival, and increased morbidity. However, there are no formal guidelines on perioperative antiseizure medication (ASM) management in patients with tumor-related epilepsy who are deemed high risk for EPS. In this study, we describe the case of a 38-year-old man with isocitrate dehydrogenase-mutant mixed glioma and two episodes of EPS manifesting with status epilepticus during prior tumor surgeries and who presented with tumor progression. The Tumor Board recommended awake craniotomy with direct electrical stimulation (DES). The patient was administered aggressive preoperative "prophylactic" ASMs by increasing the maintenance doses of lacosamide and levetiracetam by 25% 48 h before surgery. An intravenous load of fosphenytoin (20 mg/kg) was administered in the operating room before DES, followed by a maintenance dosing of 300 mg/day for 14 days. EPS did not occur, and he was discharged home on postoperative day 4. Our case illustrates that aggressive perioperative prophylactic ASM therapy beyond the maintenance ASM regimen can be considered in patients with tumor-related epilepsy at risk of EPS.

Early Postoperative Seizures Following Awake Craniotomy and Functional Brain Mapping for Lesionectomy

OBJECTIVE

Awake craniotomy with electrocorticography (ECoG) and direct electrical stimulation (DES) facilitates lesionectomy while avoiding adverse effects. Early postoperative seizures (EPS), occurring within 7 days following surgery, can lead to morbidity. However, risk factors for EPS after awake craniotomy including clinical and ECoG data are not well defined.

METHODS

We retrospectively studied the incidence and risk factors of EPS following awake craniotomy for lesionectomy, and report short-term outcomes between January 1, 2020, and December 31, 2022.

RESULTS

We included 138 patients (56 female) who underwent 142 awake craniotomies, average age was 50.78 ± 15.97 years. Eighty-eight (63.7%) patients had a preoperative history of tumor-related epilepsy treated with antiseizure medication (ASM), 12 (13.6%) with drug-resistance. All others (36.3%) received ASM prophylaxis with levetiracetam perioperatively and continued for 14 days. An equal number of cases (71) each utilized a novel circle grid or strip electrodes for ECoG. There were 31 (21.8%) cases of intraoperative seizures, 16 with EPS (11.3%). Acute abnormality on early postoperative neuroimaging (P = 0.01), subarachnoid hemorrhage (P = 0.01), young age (P = 0.01), and persistent postoperative neurologic deficits (P = 0.013) were associated with EPS. Acute abnormality on neuroimaging remained significant in multivariate analysis. Outcomes during hospitalization and early outpatient follow up were worse with EPS.

CONCLUSIONS

We report novel findings using ECoG and clinical features to predict EPS, including acute perioperative brain injury, persistent postoperative deficits and young age. Given worse outcomes with EPS, clinical indicators for EPS should alert clinicians of potential need for early postoperative EEG monitoring and perioperative ASM adjustment.

Postoperative Seizure Prophylaxis in Meningioma Resection: A Systematic Review and Meta-Analysis

BACKGROUND

Seizures in the early postoperative period may impair patient recovery and increase the risk of complications. The aim of this study is to determine whether there is any advantage in postoperative seizure prophylaxis following meningioma resection.

METHODS

This systematic review was conducted in accordance with PRISMA guidelines. PUBMED, Web of Science, Embase, Science Direct, and Cochrane were searched for papers until April 2023.

RESULTS

Among nine studies, a total of 3249 patients were evaluated, of which 984 patients received antiepileptic drugs (AEDs). No significant difference was observed in the frequency of seizure events between patients who were treated with antiepileptic drugs (AEDs) and those who were not. (RR 1.22, 95% CI 0.66 to 2.40; I2 = 57%). Postoperative seizures occurred in 5% (95% CI: 1% to 9%) within the early time period (<7 days), and 9% (95% CI: 1% to 17%) in the late time period (>7 days), with significant heterogeneity between the studies (I2 = 91% and 97%, respectively). In seizure-naive patients, the rate of postoperative seizures was 2% (95% CI: 0% to 6%) in the early period and increased to 6% (95% CI: 0% to 15%) in the late period. High heterogeneity led to the use of random-effects models in all analyses.

CONCLUSIONS

The current evidence does not provide sufficient support for the effectiveness of prophylactic AED medications in preventing postoperative seizures in patients undergoing meningioma resection. This underscores the importance of considering diagnostic criteria and conducting individual patient analysis to guide clinical decision-making in this context.

Meningioma-Related Epilepsy: A Happy Ending?

(1) Background: More than one-third of patients with meningiomas experience at least one seizure during the course of their disease, and in the 20-50% of cases, seizure represents the onset symptom. After surgery, up to 30% of patients continue to have seizures, while others may experience them later; (2) Methods: The study analyzed retrospectively the risk factors for pre-operative seizures in a large cohort of 358 patients who underwent surgery for newly diagnosed brain meningioma; (3) Results: We identified age, peritumor edema, and location as risk factors for seizure at the onset. Patients with seizures differed from patients without seizures for the following characteristics: younger average age, lower pre-operative Karnofsky Performance Status (KPS), location on the convexity, lower Simpson Grade, lower incidence of pre-operative neurological deficits, and higher incidence of pre-operative peritumor edema. After 24 months, 88.2% of patients were classified as Engel class Ia, and no correlation with disease progression was observed; (4) Conclusions: Meningioma-related epilepsy has generally a positive outcome following surgery and it seems not to be linked to disease progression, even if further studies are needed.

The clinical and genomic features of seizures in meningiomas

Meningiomas are the most common central nervous system tumors. Although these tumors are extra-axial, a relatively high proportion (10%-50%) of meningioma patients have seizures that can substantially impact the quality of life. Meningiomas are believed to cause seizures by inducing cortical hyperexcitability that results from mass effect and cortical irritation, brain invasion, or peritumoral brain edema. In general, meningiomas that are associated with seizures have aggressive features, with risk factors including atypical histology, brain invasion, and higher tumor grade. Somatic NF2 mutated meningiomas are associated with preoperative seizures, but the effect of the driver mutation is mediated through atypical features. While surgical resection is effective in controlling seizures in most patients with meningioma-related epilepsy, a history of seizures and uncontrolled seizures prior to surgery is the most significant predisposing factor for persistent postoperative seizures. Subtotal resection (STR) and relatively larger residual tumor volume are positive predictors of postoperative seizures. Other factors, including higher WHO grade, peritumoral brain edema, and brain invasion, are inconsistently associated with postoperative seizures, suggesting they might be crucial in the development of an epileptogenic focus, but do not appear to play a substantial role after seizure activity has been established. Herein, we review and summarize the current literature surrounding meningioma-related epilepsy and underscore the interaction of multiple factors that relate to seizures in patients with meningioma.

Risk factors for preoperative seizures in intracranial meningiomas

BACKGROUND

About 25% of patients with intracranial meningioma display seizures at the time of initial presentation. Hence, identification of risk factors for preoperative seizures is crucial during perioperative care of meningioma patients.

METHODS

Associations of preoperative seizures with clinical, radiological and histological variables were analyzed in 945 patients (689 females, 73% and 256 males, 27%; median age: 58 years) who underwent surgery for primary diagnosed intracranial meningioma.

RESULTS

Preoperative seizures were found in 189 patients (20%). In univariate analyses, male gender (OR=1.91, 95% CI: 1.37-2.68; P<0.001), grade II/III histology (OR=2.24, 95% CI: 1.46-3.46; P<0.001), brain invasion (OR=2.59, 95% CI: 1.45-4.63; P=001), non-skull base tumor location (OR=3.07, 95% CI: 2.13-4.41; P<0.001), heterogeneous contrast-enhancement (OR=1.60, 95% CI: 1.04-2.46; P=0.031), intratumoral calcifications (OR=1.91, 95% CI: 1.17-3.10; P=0.009), an irregular shape (OR=2.07, 95% CI: 1.32-3.26; P=0.002) as well as tumor (OR=1.01 per ccm, 95% CI: 1.00-1.02; P=0.001) and edema volumes (OR=1.01 per ccm, 95% CI: 1.00-1.01; P<0.001) were correlated with seizures. Semiology was not related to any of the analyzed variables (P>0.05, each). No associations were found between seizures and histological subtype of 832 grade I meningiomas (P=0.391). In multivariate analyses, only non-skull base tumor location (OR=3.12, 95% CI: 1.74-5.59; P<0.001) and a rising peritumoral edema volume (OR=1.01 per ccm, 95% CI: 1.00-1.01; P<0.001) were identified as independent predictors for preoperative seizures.

CONCLUSIONS

Several mostly radiological variables were identified as risk factors for epilepsy. However, multivariate analyses confirmed only peritumoral edema and non-skull base tumor location as independent predictors for preoperative seizures. None of the variables predicts semiology.

[Risk factors for de novo generalized tonic-clonic seizures in patients with supratentorial meningiomas after neurosurgical treatment]

OBJECTIVE

To identify risk factors for de novo epileptic seizures in the early postoperative period in patients with supratentorial meningiomas.

MATERIAL AND METHODS

A retrospective case-control study was conducted in a ratio of 3 to 1. The case histories of all patients with supratentorial meningiomas that met the inclusion and exclusion criteria, who underwent surgical removal of the neoplasm in 01.01.17 to 12.31.20, were studied in the neurosurgical department of the Research Institute of Emergency Medicine named after N.V. Sklifosovsky. Of 133 patients without epileptic seizures and a history of taking antiepileptic drugs before surgery, 10% (n=14) had a de novo generalized tonic-clonic seizure in the early postoperative period. Among the remaining 119 patients, 42 patients were selected to form the control group, similar in age, localization and volume of the tumor with patients in the main group. In all patients, the clinical condition, the results of preoperative and postoperative neuroimaging with contrast enhancement, the course of the intraoperative period, as well as the duration and outcomes of hospitalization were assessed.

RESULTS

The risk factors for the development of de novo seizures were an increase in the volume of cerebral edema compared with the preoperative one according to postoperative CT data and the development of hemorrhagic transformation of cerebral edema.

CONCLUSION

A prospective study is needed to determine risk factors for de novo seizures and determine prophylactic treatment.

Clinical Management of Supratentorial Non-Skull Base Meningiomas

Supratentorial non-skull base meningiomas are the most common primary central nervous system tumor subtype. An understanding of their pathophysiology, imaging characteristics, and clinical management options will prove of substantial value to the multi-disciplinary team which may be involved in their care. Extensive review of the broad literature on the topic is conducted. Narrowing the scope to meningiomas located in the supratentorial non-skull base anatomic location highlights nuances specific to this tumor subtype. Advances in our understanding of the natural history of the disease and how findings from both molecular pathology and neuroimaging have impacted our understanding are discussed. Clinical management and the rationale underlying specific approaches including observation, surgery, radiation, and investigational systemic therapies is covered in detail. Future directions for probable advances in the near and intermediate term are reviewed.

Management of epilepsy in brain tumor patients

PURPOSE OF REVIEW

A concise review of recent findings in brain tumor-related epilepsy (BTRE), with focus on the effect of antitumor treatment on seizure control and the management of antiepileptic drugs (AEDs).

RECENT FINDINGS

Isocitrate dehydrogenase mutation and its active metabolite d -2-hydroxyglutarate seem important contributing factors to epileptogenesis in BTRE. A beneficial effect of antitumor treatment (i.e. surgery, radiotherapy, and chemotherapy) on seizure control has mainly been demonstrated in low-grade glioma. AED prophylaxis in seizure-naïve BTRE patients is not recommended, but AED treatment should be initiated after a first seizure has occurred. Comparative efficacy randomized controlled trials (RCTs) are currently lacking, but second-generation AED levetiracetam seems the preferred choice in BTRE. Levetiracetam lacks significant drug-drug interactions, has shown favorable efficacy compared to valproic acid in BTRE, generally causes no hematological or neurocognitive functioning adverse effects, but caution should be exercised with regard to psychiatric adverse effects. Potential add-on AEDs in case of uncontrolled seizures include lacosamide, perampanel, and valproic acid. Ultimately, in the end-of-life phase when oral intake of medication is hampered, benzodiazepines via nonoral administration routes are potential alternatives.

SUMMARY

Management of seizures in BTRE is complex and with currently available evidence levetiracetam seems the preferred choice. Comparative efficacy RCTs in BTRE are warranted.

Chinese guideline on the application of anti-seizure medications in the perioperative period of supratentorial craniocerebral surgery

Seizures are a common symptom of craniocerebral diseases, and epilepsy is one of the comorbidities of craniocerebral diseases. However, how to rationally use anti-seizure medications (ASMs) in the perioperative period of craniocerebral surgery to control or avoid seizures and reduce their associated harm is a problem. The China Association Against Epilepsy (CAAE) united with the Trauma Group of the Chinese Neurosurgery Society, Glioma Professional Committee of the Chinese Anti-Cancer Association, Neuro-Oncology Branch of the Chinese Neuroscience Society, and Neurotraumatic Group of Chinese Trauma Society, and selected experts for consultancy regarding outcomes from evidence-based medicine in domestic and foreign literature. These experts referred to the existing research evidence, drug characteristics, Chinese FDA-approved indications, and expert experience, and finished the current guideline on the application of ASMs during the perioperative period of craniocerebral surgery, aiming to guide relevant clinical practice. This guideline consists of six sections: application scope of guideline, concepts of craniocerebral surgery-related seizures and epilepsy, postoperative application of ASMs in patients without seizures before surgery, application of ASMs in patients with seizures associated with lesions before surgery, emergency treatment of postoperative seizures, and 16 recommendations.

Predictors of postoperative seizure outcome in supratentorial meningioma

OBJECTIVE

Meningiomas are the most common primary intracranial tumor. Seizures are common sequelae of meningioma development. Meningioma patients with seizures can be effectively treated with resection, with reports of seizure freedom of 60%-90%. Still, many patients manifest persistent epilepsy. Determining factors associated with worsened seizure outcomes remains critical in improving the quality of life for these patients. The authors sought to identify clinical, radiological, and histological factors associated with worse seizure outcomes in patients with supratentorial meningioma and preoperative seizures.

METHODS

The authors retrospectively reviewed the charts of 384 patients who underwent meningioma resection from 2008 to 2020. The charts of patients with a documented history of preoperative seizures were further reviewed for clinical, radiological, operative, perioperative, histological, and postoperative factors associated with seizures. Engel class at last follow-up was retrospectively assigned by the authors and further grouped into favorable (class I) and worse (class II-IV) outcomes. Factors were subsequently compared by group using comparative statistics. Univariable and multivariable regression models were utilized to identify independent predictors of worse seizure outcome.

RESULTS

Fifty-nine patients (15.4%) were found to have preoperative seizures, of whom 57 had sufficient postoperative data to determine Engel class outcome. Forty-two patients (74%) had Engel class I outcomes. The median follow-up was 17 months. Distinct margins on preoperative imaging (p = 0.012), Simpson grade I resection (p = 0.004), postresection ischemia (p = 0.019), WHO grade (p = 0.019), and recurrent disease (p = 0.015) were found to be the strongest predictors of Engel class outcome in univariable logistic regression. MIB-1 index (p = 0.001) and residual volume (p = 0.014) at last follow-up were found to be the strongest predictors of Engel class outcome in univariable generalized linear regression. Postresection ischemia (p = 0.012), WHO grade (p = 0.022), recurrent disease (p = 0.038), and MIB-1 index (p = 0.002) were found to be the strongest independent predictors of Engel class outcomes in multivariable analysis.

CONCLUSIONS

Postresection ischemia, higher WHO grade, elevated MIB-1 index, and disease recurrence independently predict postresection seizure persistence in patients with supratentorial meningioma. Further understanding of the etiology of these markers may aid in elucidation of this complex disease process and guide management to prevent worse outcomes.

Meningioma Related Epilepsy- Pathophysiology, Pre/postoperative Seizures Predicators and Treatment

Meningiomas are the most common primary brain tumors accounting for about 30% of all brain tumors. The vast majority of meningiomas are slow-growing and of benign histopathology rendering them curable by surgery alone. Symptomatic lesions depend on the location with signs of mass effect or neurological deficits. Seizures are the presenting symptoms in approximately 30% of cases, which negatively affect quality of life, limit independence, impair cognitive functioning, as well as increase the risk for psychiatric comorbidities including depression. Although surgical resection may offer seizure freedom in 60-90% of meningiomas, seizures persist after surgical resection in approximately 12-19% of patients. Anti-seizure medications (ASMs) are employed in management, however, are limited by adverse neurocognitive side-effects and inefficacy in some patients. The potential predictors of pre- and post-operative seizures in meningioma patients have been identified in the literature. Understanding various factors associated with seizure likelihood in meningioma patients can help guide more effective seizure control and allow for better determination of risk before and after surgery.

Seizure prophylaxis in meningiomas: a systematic review and meta-analysis

INTRODUCTION

No formal indication currently exists for seizure prophylaxis in neurosurgical oncology patients. Neither have specific recommendations been made on the use of antiepileptic drugs (AED) in seizure-free patients with meningiomas scheduled for surgery. AEDs are generally prescribed on a discretionary basis, taking into consideration a range of clinical and radiological risk factors. We present a systematic review and meta-analysis exploring the effectiveness of antiepileptic prophylaxis in patients with meningioma and no history of seizures.

METHODS

We performed a systematic review of the PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and clinicaltrials.gov databases. Of a total of 4368 studies initially identified, 12 were selected for extraction of data and qualitative analysis. Based on the clinical data presented, we were only able to include 6 studies in the meta-analysis. We performed heterogeneity studies, calculated a combined odds ratio, evaluated publication bias, and conducted a sensitivity analysis.

RESULTS

AED prophylaxis in patients with meningioma and no history of seizures did not significantly reduce the incidence of post-operative seizures in comparison to controls (Mantel-Haenszel combined odds ratio, random effects model: 1.26 [95% confidence interval, 0.60-2.78]; 2041 patients). However, we are unable to establish a robust recommendation against this treatment due to the lack of prospective studies, the presence of selection bias in the studies reviewed, the likelihood of underestimation of seizure frequency during follow-up, and the strong influence of one study on the overall effect.

CONCLUSIONS

Despite the limitations of this review, the results of the meta-analysis do not support the routine use of seizure prophylaxis in patients with meningioma and no history of seizures.

Safety of intravenous tranexamic acid in patients undergoing supratentorial meningiomas resection: protocol for a randomised, parallel-group, placebo control, non-inferiority trial

INTRODUCTION

Growing evidence recommends antifibrinolytic agent tranexamic acid (TXA) to reduce blood loss and transfusions rate in various surgical settings. However, postoperative seizure, as one of the major adverse effects of TXA infusion, has been a concern that restricts its utility in neurosurgery.

METHODS AND ANALYSIS

This is a randomised, placebo-controlled, non-inferiority trial. Patients with supratentorial meningiomas and deemed suitable for surgical resection will be recruited in the trial. Patients will be randomised to receive either a single administration of 20 mg/kg TXA or a placebo of the same volume with a 1:1 allocation ratio after anaesthesia induction. The primary endpoint is the cumulative incidence of early postoperative seizures within 7 days after craniotomy. Secondary outcomes include the incidence of non-seizure complications, changes of haemoglobin level from baseline, intraoperative blood loss, erythrocyte transfusion volume, Karnofsky Performance Status, all-cause mortality, and length of stay, and total hospitalisation cost.

ETHICS AND DISSEMINATION

This trial is registered at ClinicalTrial.gov and approved by the Chinese Ethics Committee of Registering Clinical Trials (ChiECRCT20200224). The findings will be disseminated in peer-reviewed journals and presented at national or international conferences relevant to subject fields.

TRIAL REGISTRATION NUMBER

NCT04595786.

Brain infarction following meningioma surgery-incidence, risk factors, and impact on function, seizure risk, and patient-reported quality of life

In this study, we seek to explore the incidence of and potential risk factors for postoperative infarctions after meningioma surgery, in addition to the possible association with new neurological deficits, seizures, and health-related quality of life (HRQoL). A single-center cohort study was conducted, where all patients operated for an intracranial meningioma at our institution between 2007 and 2020 were screened for inclusion. Clinical data were prospectively collected in a local tumor registry, and HRQoL was assessed using both generic and disease-specific instruments. In total, 327 meningioma operations were included, and early postoperative MRIs showed peritumoral infarctions in 114 (34.9%). Median infarction volume was 4.5 ml (interquartile range 2.0-9.5) and 43 (37.7%) of the infarctions were rim-shaped, 44 (38.6%) were sector-shaped, 25 (21.9%) were a combination of rim- and sector-shaped, and two (1.8%) were remote infarctions. Permanent neurological deficits were seen in 22 patients (6.7%) and deficits were associated with infarctions (p < 0.001). There was no difference in frequency of registered postoperative epilepsy between patients with versus without infarctions. Patients with infarctions reported more future uncertainty; otherwise, there were no significant differences in disease specific HRQoL between patients with versus without infarctions. In this study, we found that peritumoral infarctions after meningioma resection are common. Most patients with permanent neurological deficits had infarctions. Yet, most infarctions were small, and although sometimes symptomatic on individual level, infarctions did not lead to significant deterioration of HRQoL on group level.

Radiomic features as a risk factor for early postoperative seizure in patients with meningioma

PURPOSE

This study aim to identify the clinical risk factors of and to develop a radiomics-based predictive model for early postoperative seizure.

METHODS

We retrospectively assessed 322 operative patients with meningioma who met the inclusion criteria from January 2014 to December 2016 at The First Affiliated Hospital of Wenzhou Medical University. Univariate and multivariate analyses were performed to determine the predictive value of clinical variables. Magnetic resonance imaging (MRI) was performed to obtain the radiomic score (Rscore) for early postoperative seizure. Radiological features were evaluated using the AK software. The minimal redundancy (mRMR) and least absolute shrinkage and selection operator (LASSO) methods were used to assess for radiomic features, and the Rscore was obtained based on radiomic characteristics using a specific formula.

RESULTS

In total, 260 patients who met the inclusion criteria were finally enrolled in this study. Among them, 20 experienced early postoperative seizure. Logistic regression analysis showed that Rscore was associated with a significantly high risk of seizure (p<0.000). Receiver operating characteristic (ROC) curve analysis revealed that the area under the ROC curve of the Rscore was 0.92 (95% confidence interval: 0.853-0.987). The model had a high accuracy for predicting early postoperative seizure.

CONCLUSIONS

The Rscore was found to be associated with a high risk of early postoperative seizures. Thus, a higher Rscore (>-1.644) can identify high-risk patients requiring intensive care.

Health-related quality of life in meningioma

Background. Meningiomas are the most common primary intracranial tumor in adults. Although frequently histologically benign, the clinical severity of a lesion may range from being asymptomatic to causing severe impairment of global function and well-being. The diversity of intracranial locations and clinical phenotypes poses a challenge when studying functional impairments, however, more recent attention to patient-reported outcomes and health-related quality of life (HRQOL) have helped to improve our understanding of how meningioma may impact a patient’s life.Methods. Treatment strategies such as observation, surgery, radiation, or a combination thereof have been examined to ascertain their contributions to symptoms, physical and cognitive functioning, disability, and general aspects of daily functioning.Results. This review explores the multidimensional nature of HRQOL and how patients may be influenced by meningiomas and their treatment.Conclusion. Overall, treatment of symptomatic meningiomas is associated with improved HRQOL, cognitive functioning, and seizure control while tumor size, location, histologic grade, and epileptic burden are associated with worse HRQOL.

Meningioma preceding CASPR2 antibody limbic encephalitis with a stroke mimic: A case report

RATIONALE

Todd paralysis (a stroke-like presentation in some patients with epilepsy) caused by limbic encephalitis (LE) is not easily distinguished from acute ischemic stroke by clinicians in the emergency room.

PATIENT CONCERNS

We report a contactin-associated protein-like 2-antibody (CASPR2-Ab)-positive patient who presented with atypical LE.

DIAGNOSES

CASPR2-Ab-positive LE was the presumed diagnosis. Re-evaluation of cerebrospinal fluid (CSF) samples revealed autoantibodies targeting CASPR2 at an immunoglobulin G titer of 1:1. The clinical presentation of subacute onset seizures, abnormal electroencephalography, hypermetabolism on positron emission tomography, good immunotherapy response, and the presence of specific antibodies in serum supports a diagnosis of autoimmune LE.

INTERVENTION

The patient received glucocorticoids (1 g for 3 days and 500 mg for 3 days), immunoglobulin (25 g for 3 days), sodium valproate (1 g for 3 days), and clonazepam (1 mg for 3 days).

OUTCOMES

Remission of temporal lobe epilepsy symptoms and cognitive dysfunction was observed. Follow-up analysis of CSF and serological examination were not approved by the patient. His Mini-Mental State Examination score improved to 21/30. Stable remission of symptoms was achieved throughout the follow-up period of 50 days.

LESSONS

Autoimmune encephalitis (AE) should be considered in cases of late-onset epilepsy following meningioma peritumoral brain edema and resection. A diagnosis of AE should be considered in patients presenting with stroke-like symptoms if the magnetic resonance imaging abnormality does not match a known vascular territory. Early and correct diagnosis is crucial because immunotherapy is usually effective for this disease.

Prophylactic AEDs Treatment for Patients With Supratentorial Meningioma Does Not Reduce the Rate of Perioperative Seizures: A Retrospective Single-Center Cohort Study

Meningiomas, the most common brain tumor, inevitably require surgical treatment. However, the efficacy of prophylactic antiepileptic drugs (AEDs), in reducing the frequency of new-onset seizures during the perioperative period remains controversial. To further clarify if prophylactic antiepileptic drug treatment for patients with meningioma had value, we reviewed the medical records of 186 supratentorial meningioma patients who were operated at our hospital between 2016 and 2018. SPSS 24.0 software was used for statistical analysis. The results of univariate analysis showed that factors including age, sex, the course of the disease (years), maximum cross-sectional area of the tumor, location of the tumor, multiple or single tumors, adjacent to the cortex, peritumoral brain edema, World Health Organization classification, and peritumoral adhesion were not associated with perioperative seizures (P >0.05). Furthermore, the results of multivariate analysis revealed hydrocephalus (OR 4.87 P = 0.05) and non-skull base location (OR 1.88 P = 0.04) were significant risk factors for perioperative in-hospital seizures. Prophylactic valproic acid treatment did not contribute to the alleviation of perioperative seizures (OR 1.76 P = 0.04). However, Multivariate logistic regression analyses excluding the patients with seizures before operation confirmed prophylactic valproic acid treatment did not reduce the frequency of seizures during the perioperative period (OR 1.84 P = 0.04). Taken together, the data suggest that prophylactic valproic acid treatment for patients with supratentorial meningioma does not reduce the rate of perioperative seizures.

Intracranial Meningiomas in the Elderly: Clinical, Surgical and Economic Evaluation. A Multicentric Experience

Simple Summary

Meningiomas are the most common intracranial tumors. Given the increase in life expectancy and the widespread access and use of brain imaging, the incidence in the elderly population (≥65 years) is continuously increasing. The risk/benefit ratio of surgery in elderly patients with intracranial meningioma has not been clearly defined because of the lack of objective measurement tools. The aim of our work to understand the risk factors associated with postsurgical outcomes and how these risk factors affected postsurgical outcomes in elderly patients with intracranial meningioma.

Abstract

Meningioma is one of the most common intracranial tumors. It is benign and slow growing in the majority of cases. Given the increase in life expectancy and the number of radiological tests performed, the incidence in the elderly population (≥65 years) is continuously increasing. The surgical outcomes and prognostic factors in this age group are unclear. A retrospective analysis of all the patients treated for intracranial meningiomas in two different Italian institutions was performed. The clinical, radiological, surgical and follow-up data were retrospectively reviewed. Statistical analyses were performed to identify relationships between factors and outcomes. We also carried out an economic analysis. We analyzed 321 patients with intracranial meningioma. The mean age was 72.6 years (range, 65–90), with a female predominance (F/M, 1.41). Pre-operative deficits, cognitive impairment and seizures (p < 0.001) were associated with a worse post-operative Karnofsky performance scale (KPS) score (<80). A high pre-operative KPS score was associated with a good clinical and neurological outcome (p < 0.001). Being aged between 65 and 74 years, low surgical timing and Simpson removal grades of I and II were associated with a good outcome (p < 0.001). The length of hospitalization was significantly related to the outcome (p < 0.001). The complication rate was 14.3%. At 6-month follow-up, the mortality rate was 2.5%. The average cost was higher in patients with a pre-operative KPS score lower than 80. The outcome of intracranial-meningioma resection in elderly individuals is favorable when the pre-operative KPS score is >80. Treatment should be patient-specific, and additional factors should be considered. Patients with poor pre-operative clinical conditions might benefit from a combined strategy with partial resection and radiosurgery in order to reduce surgical timing and the complication rate.

Seizure prophylaxis in meningiomas: A systematic review and meta-analysis

INTRODUCTION

No formal indication currently exists for seizure prophylaxis in neurosurgical oncology patients. Neither have specific recommendations been made on the use of antiepileptic drugs (AED) in seizure-free patients with meningiomas scheduled for surgery. AEDs are generally prescribed on a discretionary basis, taking into consideration a range of clinical and radiological risk factors. We present a systematic review and meta-analysis exploring the effectiveness of antiepileptic prophylaxis in patients with meningioma and no history of seizures.

METHODS

We performed a systematic review of the PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and clinicaltrials.gov databases. Of a total of 4368 studies initially identified, 12 were selected for extraction of data and qualitative analysis. Based on the clinical data presented, we were only able to include 6 studies in the meta-analysis. We performed heterogeneity studies, calculated a combined odds ratio, evaluated publication bias, and conducted a sensitivity analysis.

RESULTS

AED prophylaxis in patients with meningioma and no history of seizures did not significantly reduce the incidence of post-operative seizures in comparison to controls (Mantel-Haenszel combined odds ratio, random effects model: 1.26 [95% confidence interval, 0.60-2.78]; 2041 patients). However, we are unable to establish a robust recommendation against this treatment due to the lack of prospective studies, the presence of selection bias in the studies reviewed, the likelihood of underestimation of seizure frequency during follow-up, and the strong influence of one study on the overall effect.

CONCLUSIONS

Despite the limitations of this review, the results of the meta-analysis do not support the routine use of seizure prophylaxis in patients with meningioma and no history of seizures.

Comparative analysis of intracranial meningiomas in patients younger than 40 years

PURPOSE

Intracranial meningiomas are relatively rare in young adults, and their specific clinical features remain unclear. The authors analyzed the clinical characteristics of intracranial meningioma in patients younger than 40 years.

METHODS

Consecutive patients younger than 40 years with meningioma (n = 223) who underwent surgical treatment at our hospital from 2010 to 2018 were retrospectively reviewed. The study cases was further divided into a younger group (≤ 30 years old; n = 63) and an older group (31-40 years old; n = 160). The clinical information, radiological characteristics, intraoperative findings, and pathological outcomes were extracted from the patients' records and statistically analyzed.

RESULTS

Intracranial meningioma is uncommon in patients younger than 40 years (8.6%). The study group's most common symptoms at presentation were headaches (46.7%), visual impairment (27.8%), limb weakness (20.6%), and epilepsy (13.5%). The mean tumor size was larger (51.47 ± 50.36 cm³) in the younger group than in the older group (22.94 ± 27.20 cm³). According to multivariate analyses, young age was an independent predictor of large tumor size, and large tumor size was significantly associated with peritumoral brain edema and intraoperative blood loss.

CONCLUSION

Intracranial meningiomas in younger adult patients may have special complexity and perioperative risk due to large tumor sizes. Therefore, individualized treatment strategy is recommended, and the appropriate caution should be taken during surgery.