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  In this Article
 »  Abstract
 »  Introduction
 »  Material and methods
 »  Results
 »  Discussion
 »  Acknowledgment
 »  References

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Year : 2001  |  Volume : 49  |  Issue : 1  |  Page : 55-9

Epileptic seizures in supratentorial gliomas.


Department of Neurosurgery, Neuroscience Centre, All India Institute of Medical Sciences, New Delhi - 110 029, India.

Correspondence Address:
Department of Neurosurgery, Neuroscience Centre, All India Institute of Medical Sciences, New Delhi - 110 029, India.

  »  Abstract

Two hundred patients with supratentorial glioma; astrocytoma (pilocytic, fibrillary, gemistocytic) 82, mixed glioma (oligoastrocytoma) 46, oligodendroglioma 8, malignant (anaplastic) astrocytoma 33 and glioblastoma multiforme 31, surgically treated for the tumours and followed up for one to sixteen years, were retrospectively analysed for the incidence of pre and postoperative epileptic seizures. 122 patients (61%) had seizures preoperatively. 62 (50.8%) of them had at least one or more seizures during follow up. Seizures were persistent in 22 patients. Doubtful, or one or two minor seizures occurred in 19 cases. Six patients in this group had seizure only at the time of CT confirmed recurrence, after a seizure free interval of one to nine years. Amongst 78 patients who did not have seizures preoperatively, 24 (30.6%) developed seizures during the postoperative follow up period. Recurrent attacks were reported only by 5 patients while 15 patients had seizure(s) only at the time of recurrence of tumour. Two patients had a few seizures in the early postoperative period and none thereafter, while doubtful seizures were reported by two patients.

How to cite this article:
Tandon P N, Mahapatra A K, Khosla A. Epileptic seizures in supratentorial gliomas. Neurol India 2001;49:55


How to cite this URL:
Tandon P N, Mahapatra A K, Khosla A. Epileptic seizures in supratentorial gliomas. Neurol India [serial online] 2001 [cited 2020 Jul 2];49:55. Available from: http://www.neurologyindia.com/text.asp?2001/49/1/55/1300




   »   Introduction Top

The occurrence of epileptic attacks in patients with
brain tumours is well known and has been the subject
of a number of studies.[1],[2],[3],[4],[5],[6],[7] The reported series have
individual and institutional bias, some including
patients diagnosed and treated for brain tumours,
others deal with patients discovered to have a brain
tumour during investigation and surgical treatment for
intractable epilepsy. There are still others dealing with
specific groups like children[8] or specific tumour
types.[9],[10],[11] There is enough information regarding the
incidence of epilepsy in different types of tumours and
several publications deal with its prognostic
significance.[7],[12],[13],[14],[15] There is an obvious paucity of
information regarding the effect of treatment of the
tumour on epilepsy.[5],[6] Somewhat more information is
available on patients with brain tumours primarily
treated for epilepsy.[4],[6],[9],[16],[17] It was, therefore,
decided to review this subject in the light of an
analysis of a random series of 200 patients of
supratentorial gliomas treated in the Department of


   »   Material and methods Top

Two hundred patients of histologically verified
supratentorial gliomas, who were surgically treated
for their tumour and followed up in our clinic, for a
minimum of one year, were retrospectively analysed.
These patients were referred to the neurosurgery clinic
with a suspicion of brain tumour and not primarily for
management of epilepsy. During the period of this
study, more than 1000 cases of supratentorial gliomas
were treated in our department. The criteria for
selecting these cases were (i) patient having survived
for one year after surgery (ii) availability of complete
records for initial hospital admission and
postoperative follow up in outpatient clinic. At each
visit, besides other clinical features, history of a
seizure was specifically inquired and recorded.
Histological slides of all these patients were reviewed
recently and the final diagnosis was astrocytoma
(including pilocytic, fibrillary and gemistocytic) in 82,
mixed glioma (oligoastrocytoma) in 46,
oligodendroglioma in 8, malignant (anaplastic)
astrocytoma in 33 and glioblastoma muliforme in 31
cases. Follow up was available for one to three years
for 104, upto five years for 59, upto seven years for 22
and more than seven years for 15 cases. As a matter of
policy in our department, all patients with
supratentorial gliomas are submitted to radical
surgical removal of the tumour without any attempt to
delineate or remove the epileptogenic cortex. No pre
or peroperative EEG was recorded. Lobectomy was
performed for anterior frontal or temporal tumours,
while tumours in and around eloquent areas were
treated by intratumoural decompression.18 Except for
four cases, all patients were submitted to
postoperative radiotherapy from a Cobalt60 source.
All patients, irrespective of preoperative history of
convulsions, were given anti-epileptic medication
postoperatively (diphenylhydantoin, phenobarbital or
carbamazepine, alone or in combination).

   »   Results Top

Records of 200 patients (147 males and 53 females)
were analysed. Their age ranged between 2 years and
65 years. However, there were only 11 patients below
the age of 15. History of preoperative seizures was
recorded in 122 (61%). These included simple partial
seizures with (19) or without (39), secondary
generalization, partial complex seizures with (4) or
without (9), secondary generalization and generalized
seizures (43). Eight patients had seizures of
indeterminate nature. It was the only symptom in 12
(9.7%), the initial symptom in 81 patients (65.1%) and
it manifested sometime during the course of illness
preoperatively in 29 patients (24.3%). The incidence
of epilepsy was, however, variable in different types of
tumours, being more common amongst those with
relatively benign tumours (ranging from 60 to 75%),
less so in malignant astrocytomas (54.5%) and least
amongst the patients with glioblastoma (29.0%)
[Table I]. The incidence of seizures according to the
site of the tumour is summarized in [Table II]. The
highest incidence was in fronto parietal tumours,
involving the sensorimotor cortex (90%) and lowest in
tumours of the occipital lobe (20%). Analysis of the
type of seizures, according to the site of tumour, did
not reveal any specific features. Further analysis of the
type of seizures, according to nature of the tumour
revealed a relatively higher incidence of generalized
seizures amongst patients with astrocytoma. Amongst
those with history of preoperative seizures (122
patients), one or more seizures were reported by 62
cases (50.8%) postoperatively. A detailed analysis of
these 62 cases revealed that persistent seizures were
reported by only 22 patients. Doubtful or one or two
minor seizures, sometime in the postoperative period,
were reported by 19 patients. Six patients had a few
minor attacks in the first year or two and none
thereafter. One or more seizures occurred, at the time
of CT confirmed recurrence in 15 patients, after they
had been seizure free for one to 9 years
postoperatively [Table III].
Twenty four of 78 patients, who did not give any
history of preoperative seizures, developed a seizure
for the first time postoperatively. The seizures
heralded a recurrence (as confirmed by contrast
enhanced CT) in 15 cases. Recurrent seizures were
reported by only 5 patients. Two patients had a few
seizures in the early postoperative period and none
thereafter, while two others had one or two doubtful
seizures. Thirty four patients died during the period of
study, all except 3 due to the tumour related causes.

   »   Discussion Top

At the time of admission to the hospital, 122 out of
200 (61%) patients with supratentorial gliomas gave
history of seizures. The incidence was higher among
cases of relatively slow growing tumours
(astrocytoma-75.5%, mixed glioma-60.8%,
oligodendroglioma-62.5%) as compared to the
malignant astrocytoma (54.5%) and glioblastoma
(29.0%). This incidence is comparable to most of the
reported series.[1],[3],[5],[6],[7] Epileptic seizures were the only
symptom (12 cases) or the initial symptom (81 cases)
in 46.5% of cases. Rasmussen[6] reported patients with
supratentorial gliomas who presented with seizures
disorder of variable period, at times extending to even
10 to 25 years. One of our patients had generalized
seizures for 20 years prior to the diagnosis of the
tumour. The incidence of brain tumours occurring in
patients of all ages under treatment for epilepsy was
reported to vary from 0.6% to 20%.[6],[20],[21],[22] It has been stated that primary intracerebral tumours,
presenting with epilepsy, are relatively benign.[7]
However, we observed 5 out of 33 patients with
malignant astrocytomas to have seizures as the initial
and only symptom for 2 to 10 years. Seizures were the
initial symptom for 6 months to 18 months in 5
patients with glioblastoma.
It is generally believed that seizures, which are late
onset, those which change character over a period of
time, show poor response to medical therapy, have
prolonged post-ictal paralysis or present as a status at
onset should arouse the suspicion of a neoplastic
aetiology of epilepsy. On the other hand, it has been
generally held that epilepsy throughout childhood,
even if focal, is only rarely associated with
tumour.[23],[24] Similarly, epilepsy of long duration
(more than 8 to 10 years) specially generalized,
particularly in younger age group, has been
considered to rule out a tumour. A review of the
present series and a survey of the literature leads one
to the conclusion that these positive and negative
criteria are only indicative and cannot be relied upon
as diagnostic criterias.
One of the important reasons to undertake this study
was to evaluate the effect of surgery on the seizure
outcome; since there are surprisingly few publications
on the subject. Amongst 122 patients, who had
postoperative seizures, 53 (42.4%) did not have
postoperative seizures till the time of last follow up.
History was equivocal in 7 patients. 19 patients had no
more than one or two minor attacks and another six
had a couple of seizures in the first one or two years
and none thereafter. 15 patients had no seizure till the
time of tumour recurrence. As a matter of fact, the
recurrence of attacks after a long seizure free interval
generally heralded the recurrence of tumour. Seizures
persisted in 22 patients (18%) amongst those who had
reported seizures preoperatively.
Among 78 patients, who did not have a history of
preoperative seizures, 24 patients experienced one or
more seizures for the first time after the operation.
Majority of these cases (15) had their seizure on the
recurrence of tumour. Four patients had only a couple
of seizures throughout the follow up period, while
recurrent seizures developed only in 5 patients.
The overall impression gathered from the present
series is that the duration and frequency of
preoperatively seizures were not important factors
influencing the postoperative seizures status. There
were number of patients with frequent seizures for as
long as 5 to 10 years preoperatively, who had no
seizure after surgery. Likewise, there were those with
only a few seizures or none at all who had persistent
seizure problem postoperatively. In general, it could
be concluded that radical tumour decompression
resulted in complete relief in 42.2% cases and definite
improvement in seizure tendency till the time of
tumour recurrence in an additional 40% of cases. In
contrast, 9 out of 78, (excluding those with seizures
heralding recurrence) developed recurrent seizures for
the first time after surgery. Rasmussen,[6] in his series
of 206 cases of cerebral astrocytoma and 35 cases of
glioblastoma, whose presenting problems were
seizures, and who were operated upon using the
technique generally used for epilepsy surgery,
reported the overall reduction of seizure, upto the time
of recurrence of neoplastic growth by 60-70%. This
was similar to the results in patients with focal
epilepsy due to nontumoural lesions. Cascino, Lee et
al and Hirsch observed worthwhile reduction in
seizure activity in 80% of cases following tumour
excision only.[9],[11],[17] In another publication, Cascino et
al25 reported stereotactic tumour resection along with
the epileptogenic area to produce worthwhile
reduction in seizure tendency.
All patients in the present series were prescribed antiepileptic
drugs, irrespective of their seizure history. It
is, therefore, not possible to state whether the
relatively low incidence of postoperative seizures, 9
out of 78, (other than those heralding recurrence) was
solely due to tumour excision or due to drugs. It could,
therefore, be argued that patients without history of
preoperative seizures need not be put on prophylactic
anti-epileptic drugs, which may be restricted to only
those with history of seizures. Shaw,[26] evaluating the
utility of prophylactic anti-epileptic treatment for
postoperative cases (of all types) did not find
significant reduction in the incidence of seizures.
However, if one includes all the cases who had at least
one or more seizures during follow tip, including the
ones associated with recurrence of tumour, these add
up to a sizeable number of 86 out of 200 (43%)
patients in the present series. This may justify a
prophylactic antiepileptic therapy in the postoperative
management of patients with brain tumours. There is
a need to undertake a well controlled prospective
study to objectively decide this issue.

   »   Acknowledgment Top

The authors are thankful to the Chief of Neuroscience
Centre and their colleagues in the Department of
Neurosurgery for permitting the use of clinical
material utilised in this study. Thanks are due to Dr.
Dheerendra Prasad for his help in compiling the data.
 

  »   References Top

1.Penfield W, Erickson TC, Tarlov I : Relation of intracranial tumours and symptomatic epilepsy. Arch Neurol Psychiatry 1940; 44 : 300-315.  Back to cited text no. 1    
2.White JC, Liu CT, Mixter WJ : Focal epilepsy - a statistical study of its causes and the results of surgical treatment. I. Epilepsy secondary to intracranial tumours. N Engl J Med 1948; 238 : 891-899.  Back to cited text no. 2    
3.Lund M : Epilepsy in association with intracranial tumours. Acta Psychiat Neurol Scan Dinav(Suppl. 81) 1952; 3-149.  Back to cited text no. 3    
4.Rasmussen T, Blunndell J : Epilepsy and brain tumour. Clin Neurosurg 1961; 7 : 138-158.  Back to cited text no. 4    
5.LeBlanc FE, Rasmussen T : Cerebral seizures and brain tumours. In handbook of clinical neurology. Vinken PJ, Bruyn GW (Eds). North Holland, Amsterdam 1973; Vol 15 : 295-301.  Back to cited text no. 5    
6.Rasmussen T : Surgery of epilepsy associated with brain tumours. In advances in neurology Vol. 3. Purpura DP, Penry JK, Walter RD (Eds). Raven Press, New York. 1975; 227-229.  Back to cited text no. 6    
7.Smith DF, Hutton JL, Sandemann D et al : The prognosis of primary intracerebral tumours presenting with epilepsy: the outcome of medical and surgical management. J Neurol Neurosurg Psychiatry1991; 54 : 915-920.  Back to cited text no. 7    
8.Page LK, Lombroso CT, Matson DD : Childhood epilepsy and late detection of cerebral glioma. J Neurosurg 1969, 31: 253-261.  Back to cited text no. 8    
9.Hirsch JF : Epilepsy and brain tumours in children. J Neuroradiol1989; 16 : 292-300.  Back to cited text no. 9    
10.Winger MJ, MacDonald DR, Cairncross JG : Supratentorial anaplastic gliomas in adults: the prognostic importance of extent of resection and prior low grade glioma. J Neurosurg 1989; 71 : 487-493.  Back to cited text no. 10    
11.Lee TKY, Nakasu Y, Jefree MA et al : Indolent glioma: A cause for epilepsy. Arch Dis Child1989; 64 : 1666-1671.  Back to cited text no. 11    
12.Walker MD, Green SB, Byar DP et al : Randomized comparison of radiotherapy and nitrosoureas for the treament of malignant glioma after surgery. N Engl J Med 1980; 303 : 1323-1329.  Back to cited text no. 12    
13.Scott GM, Gibberd FB : Epilepsy and other factors in the prognosis of gliomas. Acta Neuro Scan Dinav 1980; 61 :227-239.  Back to cited text no. 13    
14.Green SB, Byar DP, Walker MD et al : Comparison of carmustine, procarbazine, and high dose methyl prednisolone as additions to surgery and radiotherapy for the treatment of malignant glioma. Cancer Treat Rep1983; 32 :121-132.  Back to cited text no. 14    
15.Shapiro WR : Therapy of adult malignant brain tumours: What have the clinical trials taught us. Semin Oncol 1986; 13: 38-45.  Back to cited text no. 15    
16.Wilden JN, Kelly PJ : CT computerized stereotactic biopsy for low density CT lesion presenting with epilepsy. J Neurol Neurosurg Psychiatry 1987; 50 : 1302-1305.  Back to cited text no. 16    
17.Cascino GD : Epilepsy and brain tumours; implications for treatment. Epilepsia1990; 31 : Suppl. 3, 37-44.  Back to cited text no. 17    
18.Tandon PN, Agarwal SP, Mahapatra AK et al : 'Radical' surgical decompression of supratentorial gliomas. Do the results justify the operation? In : Biology of brain tumour. Walker MD, Thomas DG (Eds). Martinus. Bijhorff Publ. Nitherland 1986; 277-286.  Back to cited text no. 18    
19.Rich KM, Goldering S, Gado M : Computed tomography in chronic seizure disorder caused by gliomas. Arch Neurol 1985; 42 : 26-27.  Back to cited text no. 19    
20.Smith B, Robinson GC, Lennox WG : Acquired epilepsy : A study of 535 cases. Neurology(Minneap) 1954; 4 : 19-28.  Back to cited text no. 20    
21.Huber P, Eichenberger M : Die Indikation zur neuroradiologischen untersuchung von patient mit iangdaucerendem anfallsleiden. Schwei Med Wschr 1963;93 : 616-620.  Back to cited text no. 21    
22.Dodge HW Jr : Epileptic seziures associated with mass intracranial lesions. Proc Staff Meet Mayo Clinic 1958; 33 :487-496.  Back to cited text no. 22    
23.Holowach J, Thurston DL, O'Leary J : Jacksonian seizures in infancy and childhood. J Pediatr 1958; 52 : 670-686.  Back to cited text no. 23    
24.Millichap JG, Bickford RG, Miller RH et al : The electroencephalogram in children with intracranial tumours and seizures. Neurology (Minneap) 1962; 12 : 329-336.  Back to cited text no. 24    
25.Cascino GD, Kelly PJ, Hirschorn KA et al : Stereotactic resection of intra-axial cerebral lesions in partial epilepsy. Mayo Clin Proc 1990; 65 : 1053-1060.  Back to cited text no. 25    
26.Shaw MD : Postoperative epilepsy and the efficacy of anticonvulsant therapy. Acta Neurochirurg (Suppl.) 1990; 50: 55-57.  Back to cited text no. 26    

 

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