The impact of epilepsy on the quality of life of patients with meningioma: A systematic review

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.

Suicidal ideation and attempts in brain tumor patients and survivors: A systematic review

Background

Subsequent to a diagnosis of a brain tumor, psychological distress has been associated with negative effects on mental health as well as suicidality. The magnitude of such impact has been understudied in the literature. We conducted a systematic review to examine the impact of a brain tumor on suicidality (both ideation and attempts).

Methods

In accordance with the PRISMA guidelines, we searched for relevant peer-reviewed journal articles on PubMed, Scopus, and Web of Science databases from inception to October 20, 2022. Studies investigating suicide ideation and/or attempt among patients with brain tumors were included.

Results

Our search yielded 1,998 articles which were screened for eligibility. Seven studies consisting of 204,260 patients were included in the final review. Four studies comprising 203,906 patients (99.8%) reported elevated suicidal ideation and suicide attempt incidence compared with the general population. Prevalence of ideation and attempts ranged from 6.0% to 21.5% and 0.03% to 3.33%, respectively. Anxiety, depression, pain severity, physical impairment, glioblastoma diagnosis, male sex, and older age emerged as the primary risk factors associated with increased risk of suicidal ideation and attempts.

Conclusion

Suicidal ideation and attempts are increased in patients and survivors of brain tumors compared to the general population. Early identification of patients exhibiting these behaviors is crucial for providing timely psychiatric support in neuro-oncological settings to mitigate potential harm. Future research is required to understand pharmacological, neurobiological, and psychiatric mechanisms that predispose brain tumor patients to suicidality.

Health-Related Quality of Life in Intracranial Meningioma: Current Evidence and Future Directions

Historically, largely due to the good prognosis for survival, there has been little attention paid to the possible impact of meningiomas and their treatment on health-related quality of life (HRQoL). However, in the last decade there has been increasing evidence that patients with intracranial meningiomas suffer from long-term decreases in their HRQoL. Compared with controls and normative data, meningioma patients have worse HRQoL scores both before and after intervention and continuing long term (even after >4 years of follow-up). Overall, surgery results in improvements in many aspects of HRQoL. The limited available studies investigating the impact of radiotherapy suggest that this type of treatment decreases HRQoL scores, especially in the long term. There is however only limited evidence on additional determinants of HRQoL. Patients with anatomically complex skull base meningiomas and severe comorbidities, including epilepsy, report the lowest HRQoL scores. Other tumor and sociodemographic characteristics have shown weak associations with HRQoL. Furthermore, about one-third of caregivers of meningioma patients report caregiver burden, warranting interventions to improve caregiver HRQoL. As antitumor interventions may not improve HRQoL scores to be comparable to those of the general population, more attention should be paid to the development of integrative rehabilitation and supportive care programs for meningioma patients.

Symptom burden and surgical outcome in non-skull base meningiomas

Purpose

Non-skull base meningiomas (NSBM) are a distinct entity and frequently present with focal neurological deficits. This study was designed to analyze functional and oncological outcome following microsurgical tumor resection in patients with NSBM.

Patients and methods

An analysis of 300 patients that underwent NSBM resection between 2003 and 2013 was performed. Assessment measures for functional outcome were Karnofsky Performance Scale (KPS), Medical Research Council - Neurological Performance Scale (MRC-NPS), and improvement rates of focal deficits and seizures. The extent of resection; recurrence-free survival (RFS) and tumor-specific survival (TSS) were also determined.

Results

Impaired KPS and MRC-NPS were present in 73.3% and 45.7%, respectively. Focal neurological deficits were recorded in 123 patients (41.0%), with hemiparesis (21.7%) and aphasia (9.3%) the most prevalent form of impairment. Most meningiomas were localized at the convexity (64.0%), followed by falcine tumors (20.3%). Both KPI and MRC-NPS scores were significantly improved by surgical resection. Postoperative improvement rates of 96.6%, 89.3%, 72.3%, 57.9%, and 27.3% were observed for aphasia, epilepsy, hemiparesis, cranial nerve, and visual field deficits, respectively. Long-term improvement was achieved in 83.2%, 89.3%, 80.0%, 68.4% and 54.6% of patients, respectively. Gross total resection (GTR) over subtotal resection (STR) significantly improved preoperative seizures and visual field deficits and correlated with reduced risk of new postoperative hemiparesis. Poor Simpson grade was the only significant prognostic factor in multivariate analysis for long-term functional deficit, which occurred in 7.3%. Median RFS was 45.9 months (6.0 - 151.5 months), while median TSS was 53.7 months (3.1 - 153.2 months). Both WHO grade (p= 0.001) and Simpson classification (p= 0.014 and p= 0.031) were independent significant prognostic factors for decreased RFS and TSS by multivariate analysis, respectively. Furthermore, tumor diameter > 50 mm (p= 0.039) significantly correlated with decreased TSS in multivariate analysis.

Conclusion

Surgical resection significantly and stably improves neurological deficits in patients with NSBM.

Neurocognition and Health-Related Quality of Life Among Patients with Brain Tumors

Patients with brain tumors experience great symptom burden across various domains of functioning, with associated decreases in health-related quality of life and general well-being. Impaired neurocognitive functioning is among the primary concerns of these patients. Unfortunately, most patients will experience such impairment at some point in the disease. However, impaired neurocognitive functioning, symptom burden, and well-being vary according numerous patient-, tumor-, and treatment-related factors. Recent work has furthered our understanding of these contributors to patient functioning and health-related quality of life and also points to various potential targets for prevention and intervention strategies, though more efficacious treatments remain needed.

Risk factors for the development of epilepsy in patients with brain metastases

BACKGROUND

Current guidelines do not recommend primary prophylactic anti-epileptic drug (AED) therapy for patients with brain metastases (BM). Yet, subgroups of patients at high seizure risk might still benefit from prophylaxis.

METHODS

We identified 799 patients diagnosed with BM by retrospective screening of our electronic chart system. Candidate risk factors for the development of epilepsy were tested by univariate and multivariate Cox regression models.

RESULTS

Epilepsy was diagnosed in 226 of 799 patients (28%). Risk factors for epilepsy in non-operated patients were single BM (P = 0.002, hazard ratio [HR] 3.2, 95% CI: 1.5-6.6) and detection of tumoral hemorrhage (P = 0.008, HR 2.5, 95% CI: 1.3-4.9). Preoperative seizures occurred predominantly in patients with supratentorial BM (P = 0.003, HR 20.78, 95% CI: 2.8-153.4) and lung cancer (P = 0.022; HR 2.0, 95% CI: 1.1-3.6). Postoperative seizures were associated with supratentorial localization (P = 0.017, HR 5.8, 95% CI: 1.4-24.3), incomplete resection (P = 0.005, HR 4.6, 95% CI: 1.6-13.1), and by trend for multiple brain surgeries (P = 0.095, HR 1.9, 95% CI: 0.9-4.0). These risk factors were integrated into a predictive score model for postoperative epilepsy (score sum 0-8). A gradual increase of seizure rates along with higher sum score was confirmed post hoc (score 0 = no seizures; score 8 = 48% seizures). Receiver operating characteristic analysis supported diagnostic accuracy (P = 0.00001, area under the curve = 0.75).

CONCLUSIONS

Here we have defined risk profiles for the development of BM-related epilepsy and derived a score which might help to estimate the risk of postoperative seizures and identify individuals at risk who might benefit from primary prophylactic AED therapy.

Life after surgical resection of a meningioma: a prospective cross-sectional study evaluating health-related quality of life

Background

Few studies have evaluated the health-related quality of life (HRQoL) of patients with meningiomas. Here, we report the largest prospective, longitudinal cross-sectional cohort study of HRQoL in meningiomas to date, in order to identify possible actionable determinants of global HRQoL.

Methods

Adults who had undergone resection of a grade I intracranial meningioma and were in routine follow-up at a single large tertiary center underwent HRQoL assessment using the QLQ-C30 questionnaire administered opportunistically at follow-up visits. Averaged transformed QLQ-C30 scores at 12-month intervals were compared with scores from a normative reference population, with reference to known minimal clinically meaningful difference (CMD) in scores. To evaluate for possible determinants of changes in global HRQoL, global HRQoL scores were correlated (Spearman's Rho) with subdomain and symptom scores and with interval time from surgical resection.

Results

A total of 291 postoperative patients with histologically confirmed and surgically treated grade I meningiomas consented to participation and a total of 455 questionnaires were included for analysis. Patients with meningiomas reported reduced global HRQoL at nearly every 12-month interval with clinically and statistically significant impairments at 12, 48, 108, and 120 months postoperative compared with the normative population (P < 0.05). Meningioma patients at the 12-month interval also reported a reduction of each subdomain of HRQoL assessment (P < 0.05); however, a CMD was only seen in cognitive functioning. Physical, emotional, cognitive, and social subdomains, as well as fatigue and sleep/insomnia, were significantly associated with global HRQoL at the first 12-month interval. Overall, there was no significant correlation between time from surgery and global HRQoL or the subdomain functional or symptom sections of the QLQ-C30.

Conclusions

Meningioma patients report considerable limitations in HRQoL for more than 120 months after surgery, particularly in cognitive, emotional, and social function, as well as suffering significant fatigue and sleep impairment compared with a normative reference population. The majority of these reported functional impairments and symptoms are strongly associated with global HRQoL and thus can be considered determinants of global HRQoL that if treated, have the potential to improve HRQoL for our meningioma patients. This hypothesis requires future study of targeted interventions to determine their efficacy.

Long-term control and predictors of seizures in intracranial meningioma surgery: a population-based study

BACKGROUND

The aim of this retrospective study was to investigate the long-term seizure control and antiepileptic drug (AED) prescriptions, as well as identifying predictors of seizure(s) before and after surgery in a population-based cohort of operated intracranial meningioma patients.

METHODS

A total of 113 consecutive adult (> 18 years old) patients with newly diagnosed meningioma operated at the Karolinska University Hospital between 2006 and 2008 were included and followed up until the end of 2015. Data on seizure activity and AED prescriptions were obtained through chart review and telephone interview. Logistic regression and survival analysis were applied to identify risk factors for pre- and postoperative seizures.

RESULTS

A total of 21/113 (18.6%) patients experienced seizures before surgery of which 8/21 (38.1%) went on to become seizure-free after surgery. Thirteen (14%) patients experienced new-onset seizures after surgery. The regression analysis revealed tumor diameter ≥ 3.5 cm as a risk factor for preoperative seizures (OR 3.83, 95% CI 1.14-12.87). Presence of headache (OR 0.19, 95% CI 0.05-0.76) and skull base tumor location (OR 0.14, 95% CI 0.04-0.44) decreased the risk of preoperative seizures. Postoperative seizures were associated with tumor diameter ≥ 3.5 cm (OR 2.65, 95% CI 1.06-6.62) and history of preoperative seizures (OR 3.50, 95% CI 1.55-7.90).

CONCLUSION

Seizures are common before and after intracranial meningioma surgery. Approximately one third of patients with preoperative seizures become seizure-free on long-term follow-up after surgery, while 14% experienced new-onset seizures after surgery. Larger tumor size, absence of headache, and non-skull base location were associated with preoperative seizures, while tumor size and preoperative seizures were associated with postoperative seizures.

Epilepsy and adverse quality of life in surgically resected meningioma

OBJECTIVES

Meningiomas are common intracranial tumors, and despite surgery or therapy with anti-epileptic drugs (AEDs), many patients suffer from seizures. Epilepsy has a significant impact on quality of life (QoL) in non-tumor populations, but the impact of epilepsy on QoL in patients with meningioma is unknown. Our aim was to evaluate the impact of epilepsy on QoL in patients that have undergone resection of a benign meningioma.

MATERIALS AND METHODS

We recruited meningioma patients without epilepsy (n=109), meningioma patients with epilepsy (n=56), and epilepsy patients without meningioma (n=64). QoL was measured with the Short Form 36 version 2 (SF-36), the Functional Assessment of Cancer Therapy (FACT-BR), and the Liverpool Adverse Events Profile (LAEP). Regression analyses identified significant determinants of QoL.

RESULTS

Patients with meningioma and epilepsy had poorer QoL scores than meningioma patients without epilepsy in all measures. In FACT-BR, this difference was significant. Multiple regression analyses demonstrated that current AED use had a greater impact on QoL scores than recent seizures. Other variables associated with impaired QoL included depression, unemployment, and meningioma attributed symptoms.

CONCLUSIONS

Epilepsy has a negative impact on quality of life in patients with benign meningioma. AED use is correlated with impaired QoL and raised LAEP scores, suggesting that AEDs and adverse effects may have led to impaired QoL in our meningioma patients with epilepsy. The severity of epilepsy in our meningioma population was comparatively mild; therefore, a more conservative approach to AED therapy may be indicated in an attempt to minimize adverse effects.

The role of prophylactic antiepileptic drugs for seizure prophylaxis in meningioma surgery: A systematic review

Meningiomas are the commonest type of primary brain tumours. Whilst most patients are seizure-free prior to surgery, antiepileptic drugs are frequently administered to reduce the risk of developing post-operative seizures. However, evidence to support their efficacy in providing this outcome is sparse. To this end, we performed a systematic review to assess the impact of prophylactic antiepileptic drugs on post-operative epilepsy rates in seizure-naïve patients undergoing craniotomy for resection of meningiomas. The literature search was performed using PubMed for studies published between January 1990 and November 2016. The total number of patients in each study was extracted and divided into cohorts according to administration of prophylactic antiepileptic drugs. Clinical characteristics, study type and post-operative epilepsy rates were recorded. A total of 11 studies involving 1143 patients met the selection criteria. There was no statistically significant difference in the number of patients who developed post-operative epilepsy in the cohort that received prophylactic antiepileptic drugs (20 of 766; 2.6%) and the cohort that did not (10 of 377; 2.7%) (Chi-square test; P=0.96). A detailed meta-analysis could not be performed due to the insufficiency in data reported. Based on the results of this systematic review, the routine use of antiepileptic drugs for seizure prophylaxis in seizure-naïve patients undergoing meningioma resection could not be substantiated. However, limitations of a systematic review should be considered on interpretation. High quality prospective randomised controlled trials are required to definitively answer this important clinical question.

Genetic variants and increased risk of meningioma: an updated meta-analysis

PURPOSE

Various genetic variants have been reported to be linked to an increased risk of meningioma. However, no confirmed conclusion has been obtained. The purpose of the study was to investigate potential meningioma-associated gene polymorphisms, based on published evidence.

MATERIALS AND METHODS

An updated meta-analysis was performed in September 2016. After electronic database searching and study screening, we selected eligible case-control studies and extracted data for meta-analysis, using Mantel-Haenszel statistics. P-values, pooled odds ratios (ORs), and 95% confidence intervals were calculated.

RESULTS

We finally selected eight genes with ten polymorphisms: MLLT10 rs12770228, CASP8 rs1045485, XRCC1 rs1799782, rs25487, MTHFR rs1801133, rs1801131, MTRR rs1801394, MTR rs1805087, GSTM1 null/present, and GSTT1 null/present. Results of meta-analyses showed that there was increased meningioma risk in case groups under all models of MLLT10 rs12770228 (all OR >1, P<0.001), compared with control groups. Similar results were observed under the allele, homozygote, dominant, and recessive models of MTRR rs1801394 (all OR >1, P<0.05), and the heterozygote and dominant models of MTHFR rs1801131 in the Caucasian population (all OR >1, P<0.05). However, no significantly increased meningioma risks were observed for CASP8 rs1045485, XRCC1 rs25487, rs1799782, MTHFR rs1801133, MTR rs1805087, or GSTM1/GSTT1 null mutations.

CONCLUSION

Our updated meta-analysis provided statistical evidence for the role of MLLT10 rs12770228, MTRR rs1801394, and MTHFR rs1801131 in increased susceptibility to meningioma.