Neurological complications of radiation

Case . A 48-year-old, right-hand dominant Caucasian female with a master’s degree presented with headache and imaging revealed a right parietal lesion measuring 2.2 × 2.3 cm on T2 fluid attenuated inversion recovery (FLAIR) imaging without enhancement or mass effect. She underwent gross total resection. Pathology revealed a WHO grade III anaplastic astrocytoma. She underwent concurrent chemotherapy (TMZ) and radiation (59.4 Gy). Pre-radiation neuropsychologic testing was performed after surgery and before chemoradiation. At baseline, she had high-average functioning and demonstrated difficulties with attention, concentration, executive functioning, verbal memory, and verbal fluency ( Table 25.1 ). In addition, she had symptomatic anxiety, mild depression, and fatigue. At 3 months posttreatment, her attention and verbal memory performance had improved. However, other cognitive impairments remained stable and she continued to have symptoms of depression and anxiety. Unfortunately, she lost her job during treatment and was required to find alternative employment, exacerbating her perceived stress. Neuropsychology recommended pharmacologic intervention for treatment of her mood, referral to cancer support services for psychosocial support, and discussion of employment options. At 6 months posttreatment, impairment was noted in all areas, but her symptoms of depression and anxiety were much improved (due to pharmacologic intervention).

Teaching Points . This case highlights the multifactorial nature of neurocognitive dysfunction in patients with brain tumors. Cognition may be influenced not only by the tumor and its treatment but also by associated mood symptoms, treatment-induced fatigue, psychosocial stressors, and other factors, all of which likely contributed to the deficits in this patient. She reported significant anxiety and depressive symptoms following her diagnosis. Treatment of her mood symptoms with selective serotonin reuptake inhibitor (SSRI) therapy resulted in considerable benefit on her neurocognitive performance.

Case . A 62-year-old, right-hand dominant Caucasian male presented after a fall and was found on imaging to have an enhancing 6.5 × 5.5 × 4.8 cm mass in the right frontal lobe. He underwent a right frontal craniotomy and pathology revealed glioblastoma. He subsequently underwent standard Stupp-style chemoradiation. Postsurgical, pre-radiation cognitive testing showed difficulties with effortful encoding and retrieval of novel verbal information as well as impaired visual abstract reasoning, and impaired lexical verbal fluency ( Table 25.2 ). He had average consolidation, attention and set-shifting, and semantic verbal fluency. During his treatment course, he required prolonged corticosteroid use for management of cerebral edema and complained of severe treatment-associated fatigue and excessive daytime sleepiness. His weight increased by approximately 20 pounds during the 6 months of adjuvant chemotherapy and he developed steroid-induced myopathy and steroid-induced diabetes mellitus requiring initiation of metformin. He was found to have elevated thyroid stimulating hormone (TSH) at 10.5 IU/mL and low free thyroxine (free T4) of 2.1 ng/dL and was started on levothyroxine 50 mcg/day with improvement in thyroid studies. He was also sent for a polysomnogram which revealed obstructive sleep apnea and he was recommended to initiate home continuous positive airway pressure treatment.

At his 6-month examination, his encoding skills improved, as did his retrieval for novel verbal information though his attention and verbal fluency skills declined. He did not have any emotional/behavioral disturbance at either visit and his self-reported fatigue levels were low. Currently, he is not bothered enough by the deficits in attention or verbal fluency so no empiric treatment has been pursued.

Teaching Points . This case highlights many of the factors and their management that can be considered in high-grade glioma patients with neurocognitive dysfunction. The patient in this case developed endocrinopathy, corticosteroid-associated side effects, and was found to have newly diagnosed obstructive sleep apnea. These comorbid conditions, in combination with his underlying glioma and prior treatment, presumably contributed to the findings on neurocognitive assessment. Despite this, he was managed with minimal decline or changes in overall neurocognitive status after treatment and was able to continue to live and work independently.