Seizure risk factors and management approaches in patients with brain metastases

A significant proportion of patients with brain metastases experience a seizure event during their disease course, which can impact morbidity and long-term outcomes. A host of factors elevate the risk for seizures in patients with brain metastases, including patient factors, metabolic imbalances, tumor burden, and treatment modality. While reducing tumor burden via local and systemic therapies remains a critical component to mitigating seizure events, select patients may remain at risk. The use of prophylactic anti-seizure medications may be warranted in a subset of patients, though several clinical trials and guidelines from medical societies currently recommend against prophylactic use. Variability in the use of prophylactic anti-seizure medications in clinical practice underscores the need to update our current understanding of seizure risk in the era of multi-modality treatment and to identify opportunities to improve risk stratification and management. Herein, we provide a comprehensive literature review summarizing the current standard for seizure management in patients with brain metastases and assess the impact of multi-modal therapies on seizure risk. We additionally highlight gaps in the literature and present opportunities for future investigation.