Efficacy and Tolerability of Perampanel in Brain Tumor-Related Epilepsy: A Systematic Review

Significance of miR-1290 in glioblastoma patients with epilepsy

Epilepsy is often the initial symptom in two-thirds of glioblastoma (GBM) patients. Existing studies have shown that microRNAs (miRNAs) play a crucial role in epilepsy. However, their role in epilepsy associated with glioblastoma remains unclear. The aim of our study was to investigate the correlation between miR-1290 expression in GBM patients and pre-operative seizures, as well as patient outcomes. 81 GBM patients were enrolled in our study, and an independent validation was carried out with 92 similar cases. MiRNA profiling of the 81 patients was conducted to identify differentially expressed miRNAs. In the validation cohort, key miRNAs were validated by using quantitative reverse transcriptase polymerase chain reaction (q-PCR). Additionally, functional analysis of these miRNAs was performed through Gene Ontology (GO) analysis. Our array analysis disclosed that there were seven under-expressed miRNAs in patients with preoperative seizures when compared to those without preoperative seizures. Among them, miR-1290 showed the highest fold change. Validation in an independent cohort verified that patients with favorable seizure outcomes had higher miR-1290 expression levels. Functional enrichment analysis demonstrated that the gene expression profiles associated with miR-1290 were enriched in biological processes related to transcription and cell cycle regulation, especially the functions mediated by RNA polymerase II. MiR-1290 emerges as a promising biomarker for predicting seizure susceptibility and overall survival in GBM patients. A specific evaluation of miR-1290 may lead to targeted diagnostic and therapeutic interventions, potentially providing novel strategies for enhancing patient outcomes.

To be or not to be: The dilemma over the prognostic role of epilepsy at presentation in patients with glioblastoma - a systematic review and meta-analysis

Despite some evidence of a possible link between epileptogenesis and tumorigenesis in glioblastoma, the prognostic value of epilepsy at presentation has been debated over the years. We performed a systematic review and meta-analysis to summarize all published data evaluating the prognostic significance of seizures as a presenting manifestation of glioblastoma. A comprehensive search of five databases from inception to December 2023 was conducted. Included studies underwent meta-analysis, with subgroup analyses performed to identify sources of heterogeneity. Fifteen studies were included in the analysis. Seizures were considered a favorable prognostic factor in seven studies, while eight studies found no differences in overall survival between patients with seizures and those with other presenting symptoms. Eleven studies were included in the meta-analysis. The overall pooled analysis indicated a potentially favorable prognostic impact of seizures at the clinical onset of glioblastoma (HR 0.73; 95% CI 0.61-0.87). However, subgroup analysis within studies focusing on IDH-wild type cases showed no discernible impact from preoperative seizures. Retrospective design, poor quality in reporting results, and heterogeneity in tumor characteristics and therapies are the main limitations of included studies.Future prospective studies on large, homogeneous cohorts of patients with IDH-wild type glioblastoma are warranted. Overall, these findings suggest that while seizures may hold some prognostic value, further research is essential to clarify their role. Understanding the true prognostic role of seizures at clinical onset may enhance our ability to predict patient outcomes and guide clinical decision-making.

Malignant glioma remodeling of neuronal circuits: therapeutic opportunities and repurposing of antiepileptic drugs

Tumor-associated epilepsy is the most common presenting symptom in patients diagnosed with diffuse gliomas. Recent evidence illustrates the requirement of synaptic activity to drive glioma proliferation and invasion. Class 1, 2, and 3 evidence is limited regarding the use of antiepileptic drugs (AEDs) as antitumor therapy in combination with chemotherapy. Furthermore, no central mechanism has emerged as the most targetable. The optimal timing of AED regimen remains unknown. Targeting aberrant neuronal activity is a promising avenue for glioma treatment. Clinical biomarkers may aid in identifying patients most likely to benefit from AEDs. Quality evidence is needed to guide treatment decisions.

Prevalence, clinical characteristics and outcomes of seizures in neurofibromatosis type 1: A systematic review and single arm meta-analysis

BACKGROUND

Neurofibromatosis type 1 (NF1) is a common neurocutaneous syndrome that predisposes patients to seizures. We aimed to estimate the prevalence, clinical characteristics and outcomes of seizures in NF1 patients, and analyze prognostic factors of seizures.

METHODS

Systematic searches were conducted in the PubMed, EMBASE, Web of Science, Scopus, Cochrane Library, and grey literature databases from inception to April 2024. We identified observational studies that included NF1 patients with seizures. Clinical characteristics of seizures were summarized and meta-analyses of prevalence and outcomes were conducted. We assessed publication bias using funnel plots and conducted sensitivity analysis to assess stability and reliability. Individual patient data were analyzed to evaluate prognostic factors.

RESULTS

Fourteen studies were identified from 1021 records. A total of 337 patients with seizures from 4946 NF1 patients were included. Meta-analysis indicated the overall prevalence of seizures in NF1 patients was 8.1 % (95 % CI= 5.9-10.3 %). The first seizure usually occurs in childhood, with a median age range of 3.5-12.0 years. Focal seizures (54.2 %) and generalized tonic-clonic seizures (16.8 %) were the most common types. The seizure freedom rate was 68.5 % (95 % CI= 57.5-79.5 %), mostly with one or two antiseizure medications. Cortical malformation/hippocampus sclerosis emerged as an independent risk factor for persistent seizures (OR=5.19, 95 %CI=1.27-21.18, P=0.02).

CONCLUSION

Though NF1 patients face a higher risk of seizures than the general population, the majority achieve seizure freedom. Patients with cortical malformation or hippocampus sclerosis were at a higher risk of persistent seizures.

Perampanel for Treatment of People with a Range of Epilepsy Aetiologies in Clinical Practice: Evidence from the PERMIT Extension Study

INTRODUCTION

It is important to assess the effectiveness of an antiseizure medication in treating different epilepsy aetiologies to optimise individualised therapeutic approaches. Data from the PERaMpanel pooled analysIs of effecTiveness and tolerability (PERMIT) Extension study were used to assess the effectiveness and safety/tolerability of perampanel (PER) when used to treat individuals with a range of epilepsy aetiologies in clinical practice.

METHODS

A post hoc analysis was conducted of PERMIT Extension data from individuals with a known aetiology. Retention was assessed after 3, 6 and 12 months. Effectiveness was assessed after 3, 6 and 12 months and at the last visit (last observation carried forward). Effectiveness assessments included responder rate (≥ 50% seizure frequency reduction) and seizure freedom rate (no seizures since at least the prior visit). Safety/tolerability was assessed by evaluating adverse events (AEs) and AEs leading to discontinuation.

RESULTS

PERMIT Extension included 1945 individuals with structural aetiology, 1012 with genetic aetiology, 93 with an infectious aetiology, and 26 with an immune aetiology. Retention rates at 12 months were 61.1% (structural), 65.9% (genetic), 56.8% (infectious) and 56.5% (immune). At the last visit, responder rates (total seizures) were 43.3% (structural), 68.3% (genetic), 37.0% (infectious) and 20.0% (immune), and corresponding seizure freedom rates were 15.8%, 46.5%, 11.1% and 5.0%, respectively. AE incidence rates were 58.0% (structural), 46.5% (genetic), 51.1% (infectious) and 65.0% (immune), and corresponding rates of discontinuation due to AEs over 12 months were 18.9%, 16.4%, 18.5% and 21.7%, respectively. The types of AEs reported were generally consistent across aetiology subgroups, with no idiosyncratic AEs emerging.

CONCLUSION

Although PER was effective and generally well tolerated when used to treat individuals with a range of epilepsy aetiologies in clinical practice, variability in its effectiveness and tolerability across the subgroups indicates that PER may be particularly useful for individuals with specific epilepsy aetiologies.

Neuro-oncologic Emergencies

OBJECTIVE

Neuro-oncologic emergencies have become more frequent as cancer remains one of the leading causes of death in the United States, second only to heart disease. This article highlights key aspects of epidemiology, diagnosis, and management of acute neurologic complications in primary central nervous system malignancies and systemic cancer, following three thematic classifications: (1) complications that are anatomically or intrinsically tumor-related, (2) complications that are tumor-mediated, and (3) complications that are treatment-related.

LATEST DEVELOPMENTS

The main driver of mortality in patients with brain metastasis is systemic disease progression; however, intracranial hypertension, treatment-resistant seizures, and overall decline due to increased intracranial burden of disease are the main factors underlying neurologic-related deaths. Advances in the understanding of tumor-specific characteristics can better inform risk stratification of neurologic complications. Following standardized grading and management algorithms for neurotoxic syndromes related to newer immunologic therapies is paramount to achieving favorable outcomes.

ESSENTIAL POINTS

Neuro-oncologic emergencies span the boundaries of subspecialties in neurology and require a broad understanding of neuroimmunology, neuronal hyperexcitability, CSF flow dynamics, intracranial compliance, and neuroanatomy.

Intrinsic brain activity differences in perampanel-responsive and non-responsive drug-resistant epilepsy patients: an EEG microstate analysis

Background

Drug-resistant epilepsy (DRE) patients exhibit aberrant large-scale brain networks. Perampanel may be a therapeutic option for controlling seizures in these patients.

Objective

We aim to explore the differences of resting-state electroencephalogram (EEG) microstate in perampanel-responsive and non-responsive DRE patients.

Design

Retrospective study.

Methods

Clinical data were collected from DRE patients who received perampanel treatment at the Fujian Medical University Union Hospital from June 2020 to September 2021, with a minimum follow-up of 6 months. Patients were classified into three groups based on the extent of reduction in seizure frequency: non-responsive (seizure reduction <50%), responsive (seizure reduction >50% but not seizure-free), and seizure-free. Resting-state EEG data sets of all participants were subjected to EEG microstate analysis. The study comprehensively compared the mean duration, frequency per second, and temporal coverage of each microstate among the three groups.

Results

A total of 76 perampanel-treated DRE patients were categorized into three groups based on their response to treatment: non-responsive (n = 20), responsive (n = 36), and seizure-free (n = 20), according to the degree of seizure frequency reduction. The results of EEG microstate analysis revealed no statistically significant distinctions in frequency, duration, and coverage of microstate D in these DRE patients. However, the seizure-free group showed significantly increased duration and coverage of microstate A, frequency and coverage of microstate B, and significantly decreased duration, frequency, and coverage of microstate C when compared with the other groups.

Conclusion

Microstate A, B, and D is associated with the sensorimotor network, visual network, salience network, and attention network, respectively. This study demonstrates statistically significant differences in the sensorimotor, visual, and salience networks, but not in the attention network, between perampanel-responsive and non-responsive DRE patients.

Neuromodulation for Brain Tumors: Myth or Reality? A Narrative Review

In recent years, research on brain cancers has turned towards the study of the interplay between the tumor and its host, the normal brain. Starting from the establishment of a parallelism between neurogenesis and gliomagenesis, the influence of neuronal activity on the development of brain tumors, particularly gliomas, has been partially unveiled. Notably, direct electrochemical synapses between neurons and glioma cells have been identified, paving the way for new approaches for the cure of brain cancers. Since this novel field of study has been defined "cancer neuroscience", anticancer therapeutic approaches exploiting these discoveries can be referred to as "cancer neuromodulation". In the present review, we provide an up-to-date description of the novel findings and of the therapeutic neuromodulation perspectives in cancer neuroscience. We focus both on more traditional oncologic approaches, aimed at modulating the major pathways involved in cancer neuroscience through drugs or genetic engineering techniques, and on electric stimulation proposals; the latter is at the cutting-edge of neuro-oncology.