What is New in the Management of Epilepsy in Gliomas?

OPINION STATEMENT: Seizures represent a common symptom in low- and high-grade gliomas. Tumor location and histology influence the risk for epilepsy. Some molecular factors (BRAF V 600E mutations in glioneuronal tumors and IDH1/2 mutations in diffuse grade II and III gliomas) are molecular factors that are relevant for diagnosis and prognosis and have been associated with the risk of epilepsy as well. Glutamate plays a central role in epileptogenicity and growth of glial and glioneuronal tumors, based on the release of glutamate from tumor cells that enhances excitotoxicity, and a downregulation of the inhibitory GABAergic pathways. Several potential targets for therapy have been identified, and m-TOR inhibitors have already shown activity. Gross total resection is the strongest predictor of seizure freedom in addition to clinical factors, such as preoperative seizure duration, type, and control with antiepileptic drugs (AEDs). Radiotherapy and chemotherapy with alkylating agents (procarbazine, CCNU, vincristine, temozolomide) are effective in reducing the frequency of seizures in patients with pharmacoresistant epilepsy. Newer AEDs (in particular levetiracetam and lacosamide) seem to be better tolerated than the old AEDs (phenobarbital, phenytoin, carbamazepine), but randomized clinical trials are needed to prove their superiority in terms of efficacy.