Management of Epilepsy in the Brain Tumour Patient: Current Concepts and Practical Approaches

Brain Tumour-Related Epilepsy (BTRE) is among the most common, disabling and feared complications of primary and metastatic brain tumours. Seizures cause significant suffering, psychosocial burden, reduced quality of life and lead inevitably to the loss of a driving license. The mechanisms underlying BTRE are multifactorial, including tumour-driven alterations in neuronal excitability and pro-epileptogenic metabolites. Management is more challenging than idiopathic epilepsy due to high rates of drug resistance, the natural history of brain tumours and potential interactions between anti-seizure medications (ASMs) and chemotherapy/steroids. This review summarises the pathophysiology of BTRE, outlines risk factors, and provides practical recommendations for ASM selection, prophylaxis, withdrawal, and the role of surgery, radiotherapy, chemotherapy, and neuromodulation. Updated clinical evidence supports the use of non-enzyme-inducing ASMs as first line treatment as these do not interact with chemotherapy/steroids and are better tolerated than the first generation ASMs. ASM prophylaxis is not recommended and ASM withdrawal, particularly in patients with gliomas, should be made only after careful consideration of the patient's seizure history and the stability of their disease.