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Bozkurt G, Mammadkhanli O, Ozden M. Posterior Reversible Encephalopathy Syndrome Developing after Aggressive Posterior Fossa Tumor Surgery. Asian J Neurosurg 2022; 17:511-514. [DOI: 10.1055/s-0042-1757219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
AbstractPosterior reversible encephalopathy syndrome (PRES) is a rare neurologic disorder, having such common radiological findings as vasogenic edema and white matter changes in watershed areas. The clinic and radiological outcome may not be reversible in 10 to 20% of patients, like in the case of our patient. Here, we discuss the pathogenetic factors that are essential in developing PRES after posterior fossa surgery. A 4-year-old female was admitted to our clinic with a recurrent/residual mass in the posterior fossa. She previously underwent posterior fossa surgery three times (for what was diagnosed as anaplastic astrocytoma through pathohistology) in another center. She was operated thrice in 5 days, and the tumor radically removed. Two days later, after the last surgery, while waking up, our patient developed seizures and altered consciousness. Her neurological condition was severe. Magnetic resonance imaging findings were compatible with those of PRES. Our patient had multiple risk factors for PRES that were as follows: multiple posterior fossa surgeries, anamnesis of chemotherapy and radiotherapy, high-dose steroid use, intracranial pressure changes, and hypertensive attacks due to surgical manipulation. In preventing the development of PRES, we should beware of sudden changes in blood pressure during surgery and meticulously manipulate the brain stem to avoid any disturbance of the central nervous system homeostasis. PRES may transform into real encephalopathy. If the patient has some of these risk factors, PRES would probably develop after surgery.
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Affiliation(s)
- Gokhan Bozkurt
- Department of Neurosurgery, Acibadem Maslak Hospital, Istanbul, Turkey
| | - Orkhan Mammadkhanli
- Faculty of Medicine, Medical Park Ankara Hospital, Yuksek Ihtisas University, Ankara, Turkey
| | - Mahmut Ozden
- Department of Neurosurgery, Memorial Bahcelievler Hospital, Istanbul, Turkey
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Shash H, Aldaama S, Omer H, Alafghani S. Different Clinicoradiological Characteristics of Posterior Reversible Encephalopathy Syndrome in Pediatric Oncology and Post-Bone Marrow Transplantation Cases: A Retrospective Study. Front Neurol 2022; 13:836033. [PMID: 35599741 PMCID: PMC9120546 DOI: 10.3389/fneur.2022.836033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/29/2022] [Indexed: 11/23/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is receiving increasing recognition in pediatrics. However, comparisons between PRES in pediatric oncology and post-bone marrow transplantation (BMT) are lacking. Therefore, we aimed to describe the risk factors and clinical and radiological features of PRES and investigate the differences between PRES in pediatric oncology and post-BMT. The PRES data of 13 patients from our center were combined with those of 217 cases from the PubMed, Scopus, and Web of Science databases. The patients were divided into either an oncology or a post-BMT group. We included 230 patients in the analysis, 26.1% of whom belonged to the post-BMT group. Oncology patients developed PRES at a younger age (p = 0.010) and were more likely to develop encephalopathy (p = 0.004). Systemic hypertension (S-HTN) preceding PRES occurred in 43.5% (66/154) of patients. Post-BMT patients were more likely to have S-HTN (p = 0.003). Cyclosporine levels were detected in 37 patients; 40.5% had supra-therapeutic levels. The radiological findings were atypical in 74.3% of patients, and delayed repeated imaging increased the occurrence of resolution (p = 0.004). Sixteen (7%) patients developed PRES recurrence after a median of 8 weeks, with the between-group difference being non-significant. Oncology patients were more likely to develop chronic epilepsy, while BMT patients were more likely to develop rare neurologic abnormalities (p < 0.001). In conclusion, atypical clinical presentation and imaging findings should not hinder the diagnosis of PRES. S-HTN is a risk factor, particularly in post-BMT patients. Supra-therapeutic levels of cyclosporine and previous exposure to immunosuppression did not increase the risk of recurrence.
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Affiliation(s)
- Hwazen Shash
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Department of Pediatrics, King Fahad Hospital of the University, Al-Khobar, Saudi Arabia
- *Correspondence: Hwazen Shash ; orcid.org/0000-0002-4128-9504
| | - Saad Aldaama
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Hala Omer
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Sameera Alafghani
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
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Foulser PFG, Senthivel N, Downey K, Hart PE, McGrath SE. Posterior reversible encephalopathy syndrome associated with use of Atezolizumab for the treatment of relapsed triple negative breast cancer. Cancer Treat Res Commun 2022; 31:100548. [PMID: 35305364 DOI: 10.1016/j.ctarc.2022.100548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 06/14/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a complex neurological disorder with multiple clinical manifestations including headaches, seizures, and altered mental status. It is associated with many conditions including malignancy and medications including chemotherapy and immunotherapy. We report the case of a 56-year old female with a history of advanced triple negative breast cancer treated with atezolizumab (a PD-L1 inhibitor), paclitaxel and ipatasertib (investigational AKT inhibitor), who developed hypertension, confusion, and imaging findings consistent with PRES.
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Affiliation(s)
- Peter F G Foulser
- Royal Marsden Hospital, Sutton, Downs Road, Sutton, SM2 5PT, United Kingdom.
| | | | - Kate Downey
- Royal Marsden Hospital, Sutton, Downs Road, Sutton, SM2 5PT, United Kingdom
| | - Paul E Hart
- Royal Marsden Hospital, Sutton, Downs Road, Sutton, SM2 5PT, United Kingdom
| | - Sophie E McGrath
- Royal Marsden Hospital, Sutton, Downs Road, Sutton, SM2 5PT, United Kingdom
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Thakkar JP, Prabhu VC, Rouse S, Lukas RV. Acute Neurological Complications of Brain Tumors and Immune Therapies, a Guideline for the Neuro-hospitalist. Curr Neurol Neurosci Rep 2020; 20:32. [PMID: 32596758 DOI: 10.1007/s11910-020-01056-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE OF REVIEW Patients with brain tumors presenting to the emergency room with acute neurologic complications may warrant urgent investigations and emergent management. As the neuro-hospitalist will likely encounter this complex patient population, an understanding of the acute neurologic issues will have value. RECENT FINDINGS We discuss updated information and management regarding various acute neurologic complications among neuro-oncology patients and neurologic complications of immunotherapy. Understanding of the acute neurologic complications associated with central nervous system tumors and with common contemporary cancer treatments will facilitate the neuro-hospitalist management of these patient populations. While there are aspects analogous to the diagnosis and management in the non-oncologic population, a number of unique features discussed in this review should be considered.
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Affiliation(s)
- Jigisha P Thakkar
- Department of Neurology, Stritch School of Medicine, Loyola University Medical Center, 2160 S. 1st Avenue, Bldg 105, Room 2700, Maywood, IL, 60153, USA. .,Department of Neurosurgery, Stritch School of Medicine, Loyola University Chicago, 2160 S. 1st Avenue, Bldg 105, Room 1900, Maywood, IL, 60153, USA.
| | - Vikram C Prabhu
- Department of Neurosurgery, Stritch School of Medicine, Loyola University Chicago, 2160 S. 1st Avenue, Bldg 105, Room 1900, Maywood, IL, 60153, USA
| | - Stasia Rouse
- Department of Neurology, Stritch School of Medicine, Loyola University Medical Center, 2160 S. 1st Avenue, Bldg 105, Room 2700, Maywood, IL, 60153, USA
| | - Rimas V Lukas
- Department of Neurology, Northwestern University Feinberg School of Medicine, 710 N. Lake Shore Drive, Abbott Hall 1114, Chicago, IL, 60611, USA.,Lou and Jean Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, 60611, USA
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Di Stefano V, Rispoli MG, Onofrj M, De Angelis MV. Tumour-like presentation of atypical posterior reversible encephalopathy syndrome with prominent brainstem involvement. BMJ Case Rep 2020; 13:13/1/e231687. [PMID: 31919058 DOI: 10.1136/bcr-2019-231687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Typical posterior reversible encephalopathy syndrome (PRES) is a clinical-neuroradiological entity characterised by bilateral white matter oedema, which is usually symmetrical and totally reversible in 2-3 weeks. A 46-year-old man presented with a persistent headache and visual blurring in the right eye. On admission, the clinical examination revealed minimal unsteadiness of gait and elevated blood pressure. A brain MRI showed a hyperintense signal on T2-weighted sequences in the whole brainstem, extended to the spinal cord (C2-C6), the left insula and the right cerebellum. When his blood pressure was controlled, his symptoms gradually improved. The follow-up MRI scan at 3 weeks revealed a dramatic regression of the hyperintense lesions on T2-weighted sequences. The differential diagnosis of PRES is very wide, especially in the case of conspicuous brainstem involvement. Treatable causes of white matter oedema should be always kept in mind to avoid misdiagnosis and prevent complications, such as intracranial haemorrhage.
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Affiliation(s)
- Vincenzo Di Stefano
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy
| | | | - Marco Onofrj
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy
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Sun LR, Cooper S. Neurological Complications of the Treatment of Pediatric Neoplastic Disorders. Pediatr Neurol 2018; 85:33-42. [PMID: 30126755 DOI: 10.1016/j.pediatrneurol.2018.05.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/25/2018] [Indexed: 01/19/2023]
Abstract
Neurological complications resulting from childhood cancer treatments are common. Treatment for childhood neoplastic disorders is often multimodal and may include procedures, cranial irradiation, chemotherapy, transplant, and immunotherapy, each of which carries distinct neurological risks. Procedures, such as lumbar punctures, are commonly used in this population for diagnostic purposes as well as intrathecal medication administration. Surgery is associated with an array of potential neurological complications, with posterior fossa syndrome being a common cause of morbidity in pediatric brain tumor patients after neurosurgical resection. Cranial irradiation can cause late neurological sequelae such as stroke, cerebral vasculopathy, secondary malignancy, and cognitive dysfunction. Neurotoxic effects of chemotherapeutic agents are common and include neuropathy, coagulopathy causing stroke or cerebral sinovenous thrombosis, encephalopathy, seizures, cerebellar dysfunction, myelopathy, and neuropsychologic difficulties. Hematopoietic stem cell transplant has a high risk of neurological complications including central nervous system infection, seizures, and stroke. Immunotherapies, including chimeric antigen receptor-modified T-cells (CAR T-cells) and immune checkpoint inhibitors, are emerging as potentially effective strategies to treat some types of childhood cancer, but may carry with them substantial neurotoxicity which is just beginning to be recognized and studied. With evolving treatment protocols, childhood cancer survivorship is increasing, and the role of the neurologist in managing both the acute and chronic neurological consequences of treatment is becoming more important. Prevention, early recognition, and treatment of therapy-associated neurotoxicity are imperative to ensuring children can remain on the most effective therapeutic regimens and to improve the neurological function and quality of life of childhood cancer survivors.
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Affiliation(s)
- Lisa R Sun
- The Johns Hopkins University School of Medicine, Department of Neurology, Division of Pediatric Neurology, Baltimore, Maryland; The Johns Hopkins University School of Medicine, Department of Neurology, Division of Cerebrovascular Neurology, Baltimore, Maryland.
| | - Stacy Cooper
- The Johns Hopkins University School of Medicine, Department of Oncology, Division of Pediatric Oncology, Baltimore, Maryland
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Syndrome d'encéphalopathie postérieure réversible ou Posterior Reversible Encephalopathy Syndrome (PRES) secondaire au bevacizumab. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.1007/s13341-017-0788-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
This chapter provides an overview of infectious syndromes, pathogens, and diagnostic testing modalities for central nervous system infections in the immunocompromised host.
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Posterior Reversible Encephalopathy Syndrome and Cerebral Sinus Thrombosis in a Case of Pediatric B-Cell ALL. J Pediatr Hematol Oncol 2017; 39:e71-e73. [PMID: 28060109 DOI: 10.1097/mph.0000000000000728] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) and cerebral sinus thrombosis are 2 known complications of acute lymphoblastic leukemia and its treatment. We describe a patient with acute lymphoblastic leukemia whose course was complicated by both of these conditions. This case is novel both for the fact that PRES developed before the initiation of therapy and that PRES was followed shortly by the development of cerebral sinus thrombosis. Our patient's story raises questions about our current understanding of the pathophysiology of PRES, and it suggests that PRES may actually be a predisposing risk factor for cerebral sinus thrombosis.
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Posterior Reversible Encephalopathy Syndrome Associated With Dose-adjusted EPOCH (Etoposide, Prednisone, Vincristine, Cyclophosphamide, Doxorubicin) Chemotherapy. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:225-230. [PMID: 28169156 DOI: 10.1016/j.clml.2016.12.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 11/22/2016] [Accepted: 12/06/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The purpose of our study was to identify the key risk factors for the development of posterior reversible encephalopathy syndrome (PRES) after administration of the combination chemotherapy regimen, DA-EPOCH (dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin). MATERIALS AND METHODS We performed a retrospective medical record review of patients receiving DA-EPOCH with or without rituximab (DA-EPOCH ± R) at our institution from July 2012 to September 2014. The patients were screened for evidence of severe neurotoxicity through identification of requests for neurology consultations or neuroimaging studies. Patients with evidence of central nervous system (CNS) neurotoxicity were reviewed in detail to identify documented cases of PRES. The key risk factors assessed included rituximab administration sequence, and the presence of CNS insults, fluid status or electrolyte abnormalities, organ dysfunction, and hypertension. RESULTS A total of 44 patients received DA-EPOCH ± R at our institution from July 2012 to September 2014. Of these 44 patients, 3 (7%) were diagnosed with PRES. The patients who developed PRES were more likely to have a pre-existing CNS insult, fluid status or electrolytes abnormalities, and hypertension. CONCLUSION To the best of our knowledge, the present study is the first description of PRES associated with DA-EPOCH. The key risk factors for the development of PRES identified in our study included hypertension, fluid imbalance, electrolyte abnormalities, baseline organ dysfunction, a high tumor burden, and the presence of pre-existing CNS insults during chemotherapy, such as CNS infection. Patients with these risk factors appear to have a greater risk of developing PRES and should be monitored closely during treatment.
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Pikija S, Pilz G, Gschwandtner G, Rösler C, Schlick K, Greil R, Sellner J. Panitumumab-Associated Encephalopathy after Accidental Intra-arterial Application through Dislocated Central Venous Access Device. Front Neurol 2016; 7:196. [PMID: 27872609 PMCID: PMC5098172 DOI: 10.3389/fneur.2016.00196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/24/2016] [Indexed: 11/13/2022] Open
Abstract
Acute central nervous system (CNS) toxicity and immune-related side effects are increasingly recognized with the use of monoclonal antibodies for cancer therapy. Here, we report a patient who developed of acute-onset encephalopathy and coma, which began shortly after administration of panitumumab for the treatment of metastatic colorectal cancer. Echocardiography revealed that the drug had been infused into the left cardiac ventricle via a dislocated central venous line. Diffusion-weighted magnetic resonance imaging disclosed multiple cortical hyperintensities, which were preferentially located in the frontal lobes. While the neurological condition improved within a few days, the patient died 4 weeks later. It seems likely that the administration of the antibody via the intra-arterial route contributed to the development of this condition. Toxic encephalopathy may be a hitherto unrecognized complication of panitumumab treatment and should be taken into consideration in patients developing CNS symptoms undergoing this therapy.
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Affiliation(s)
- Slaven Pikija
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Georg Pilz
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Gerald Gschwandtner
- Department of Geriatric Medicine, Christian Doppler Medical Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Cornelia Rösler
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Konstantin Schlick
- Laboratory of Immunological Molecular Cancer Research, Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Diseases, Rheumatology, Oncologic Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Richard Greil
- Laboratory of Immunological Molecular Cancer Research, Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Diseases, Rheumatology, Oncologic Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg, Salzburg, Austria; Department of Neurology, Klinikum rechts der Isar, Technische Universität München, München, Germany
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Shields LBE, Johnson JR, Shields CB. Posterior reversible encephalopathy syndrome following a thoracic discectomy–induced dural leak: case report. J Neurosurg Spine 2016; 25:586-590. [DOI: 10.3171/2016.4.spine1623] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by headaches, altered mental status, seizures, and visual disturbances. Classic MRI findings include white matter changes of the parieto-occipital regions. This syndrome has been encountered in myriad medical illnesses, including hypertension, preeclampsia/eclampsia, and immunosuppressive conditions. While the pathogenesis of the disorder is unclear, vasoconstriction and hypoperfusion leading to brain ischemia and vasogenic edema have been implicated as potential mechanisms. The authors present, to the best of their knowledge, the first case of PRES following a thoracic spinal surgery–induced dural leak noted on resection of the fifth rib during a thoracotomy for a T4–5 discectomy. Brain MRI revealed large areas of increased FLAIR and T2 hyperintensity in the superior posterior frontal lobes, superior and medial parietal lobes, and bilateral occipital lobes. Following repair of the CSF leak, the patient's symptoms resolved. Spinal surgeons should be alert to the potentially life-threatening condition of PRES, especially in a hypertensive patient who experiences surgery-induced dural leakage. The development of a severe positional headache with neurological signs is a red flag that suggests the presence of PRES. Prompt attention to the diagnosis and treatment of this condition by repairing the dural leak via surgery or expeditious blood patch increases the likelihood of a favorable outcome.
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Affiliation(s)
| | | | - Christopher B. Shields
- 1Norton Neuroscience Institute,
- 2Norton Healthcare; and
- 3Department of Anatomical Science and Neurobiology, University of Louisville, School of Medicine, Louisville, Kentucky
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Wong K, Lee M, Davis ID, Parente P, Mckendrick J, Pezaro C. Posterior reversible encephalopathy syndrome mimicking brain metastases in a patient with metastatic transitional cell carcinoma. Asia Pac J Clin Oncol 2016; 13:e534-e536. [DOI: 10.1111/ajco.12510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 02/09/2016] [Accepted: 04/11/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Kelsey Wong
- Eastern Health Clinical School; Monash University; Victoria Australia
| | - Margaret Lee
- Oncology Unit; Eastern Health; Melbourne Victoria Australia
| | - Ian D. Davis
- Eastern Health Clinical School; Monash University; Victoria Australia
- Oncology Unit; Eastern Health; Melbourne Victoria Australia
| | - Phillip Parente
- Eastern Health Clinical School; Monash University; Victoria Australia
- Oncology Unit; Eastern Health; Melbourne Victoria Australia
| | - Joseph Mckendrick
- Eastern Health Clinical School; Monash University; Victoria Australia
- Oncology Unit; Eastern Health; Melbourne Victoria Australia
| | - Carmel Pezaro
- Eastern Health Clinical School; Monash University; Victoria Australia
- Oncology Unit; Eastern Health; Melbourne Victoria Australia
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Budhoo A, Mody GM. The spectrum of posterior reversible encephalopathy in systemic lupus erythematosus. Clin Rheumatol 2015; 34:2127-34. [PMID: 26298534 DOI: 10.1007/s10067-015-3055-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/12/2015] [Accepted: 08/12/2015] [Indexed: 11/30/2022]
Abstract
Our aim was to compare our South African cohort of systemic lupus erythematosus (SLE) and posterior reversible encephalopathy syndrome (PRES) with other published series. We reviewed the records of 10 patients with SLE and PRES seen over a 10-year period and their demographic data, clinical manifestations, laboratory tests, imaging findings, and outcome were recorded. We identified 10 females who included six Indians, three mixed ethnicity, and one African Black. Three patients had PRES at the onset of SLE. The most common manifestations at presentation were seizures (100 %), hypertension (80 %), and altered mental state (50 %). On neuroimaging, nine patients had bilateral involvement, and the occipital (90 %), parietal (90 %), and frontal lobes (50 %) were most commonly involved. The risk factors for PRES were disease activity (90 %), renal disease (80 %) and hypertension (80 %). Ninety percent of the patients were on immunosuppressive therapy. Immunosuppressive therapy was increased in six patients (60 %), continued in two and reduced in two patients after the diagnosis of PRES. Seven patients recovered completely and three patients died from co-morbidities. A review of the larger case series of SLE and PRES showed that the presentation and neuroimaging findings were similar; most patients had active disease at the time of PRES and the majority of patients required intensification of immunosuppressive therapy. We have shown that the majority of patients with SLE have active disease at the time of PRES, and they require an increase in their immunosuppressive therapy.
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Affiliation(s)
- Amritha Budhoo
- Department of Rheumatology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Girish M Mody
- Department of Rheumatology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa.
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Conry RM, Sullivan JC, Nabors LB. Ipilimumab-induced encephalopathy with a reversible splenial lesion. Cancer Immunol Res 2015; 3:598-601. [PMID: 25922203 DOI: 10.1158/2326-6066.cir-15-0035] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 03/18/2015] [Indexed: 11/16/2022]
Abstract
Ipilimumab, an anticytotoxic T-lymphocyte antigen (CTLA)-4 monoclonal antibody, is a first-line therapy for stage IV melanoma. Although high-grade immune-related adverse events occur in 25% of patients receiving ipilimumab, serious neurologic toxicity, primarily consisting of transient sensory and motor neuropathies, affects less than 1% of patients. We present a case report of a patient with melanoma who received high-dose ipilimumab at 10 mg/kg as first-line therapy for metastatic disease. After the third dose, the patient developed "mild" encephalopathy with a reversible splenial lesion (MERS) of the corpus callosum by MRI and neurogenic bladder, two novel immune-related adverse events during checkpoint inhibition. In addition to headache, delirium, and altered consciousness commonly seen with MERS, the patient also developed tremor, gait instability, paresthesias, and neurogenic bladder. The latter two symptoms were thought to represent sensory and autonomic neuropathies, respectively. The syndrome gradually resolved following intravenous methylprednisolone at 2 mg/kg divided twice daily for 5 days and a slow taper of oral prednisone over 8 weeks.
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Affiliation(s)
- Robert M Conry
- Division of Hematology Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Joseph C Sullivan
- Neuroradiology Section, Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Louis B Nabors
- Neuro-Oncology Program, Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
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Kamiya-Matsuoka C, Cachia D, Olar A, Armstrong TS, Gilbert MR. Primary brain tumors and posterior reversible encephalopathy syndrome. Neurooncol Pract 2014; 1:184-190. [PMID: 26034631 PMCID: PMC4369712 DOI: 10.1093/nop/npu024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic encephalopathic state associated with reversible cerebral vasogenic edema. It is an increasingly recognized occurrence in the oncology population. However, it is very uncommon in patients with primary brain tumors (PBTs). The aim of this study was to analyze the clinicoradiological features and report the clinical outcomes of PRES in PBT patients. METHODS We identified 4 cases with PBT who developed PRES at MD Anderson Cancer Center (MDACC) between 2012 and 2014. Clinical and radiological data were abstracted from their records. In addition, we also solicited 8 cases from the literature. RESULTS The median age at PRES onset was 19 years, male-to-female ratio was 1:1, and the syndrome occurred in patients with ependymoma (n = 4), glioblastoma (n = 3), diffuse intrinsic pontine glioma (DIPG; n = 3), juvenile pilocytic astrocytoma (n = 1), and atypical meningioma (n = 1). Two glioblastomas and 2 DIPG cases received bevacizumab and vandetanib before the onset of symptoms, respectively. The most common clinical presentation was seizures (n = 7). Three MDACC patients recovered completely in 3-4 weeks after the onset of symptoms. One patient died due to active cancer and several comorbidities including PRES. CONCLUSIONS Hypertension seems to be the most important coexisting risk factor for development of PRES; however, the potential effects of chemotherapeutic agents in the pathogenesis of PRES should also be examined. The clinicoradiological course of PRES in PBT patients did not vary from the classical descriptions of PRES found in other causes. PRES must be considered as part of the differential diagnosis in patients with PBTs presenting with seizures or acute encephalopathy.
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Affiliation(s)
| | | | - Adriana Olar
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas (C.K.-M., D.C., T.S.A., M.R.G.); Department of Family Health, The University of Texas Health Science Center School of Nursing, Houston, Texas (T.S.A.); Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas (A.O.)
| | - Terri S. Armstrong
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas (C.K.-M., D.C., T.S.A., M.R.G.); Department of Family Health, The University of Texas Health Science Center School of Nursing, Houston, Texas (T.S.A.); Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas (A.O.)
| | - Mark R. Gilbert
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas (C.K.-M., D.C., T.S.A., M.R.G.); Department of Family Health, The University of Texas Health Science Center School of Nursing, Houston, Texas (T.S.A.); Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas (A.O.)
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Kamiya-Matsuoka C, Shroff S, Tatsui CE, Tremont-Lukats IW, Gilbert MR. Sinking skin flap syndrome in glioblastoma. BMJ Case Rep 2014; 2014:bcr-2014-207158. [PMID: 25398923 DOI: 10.1136/bcr-2014-207158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Sinking skin flap syndrome (SSFS) is a rare neurological complication in patients with traumatic haemorrhage, stroke or cerebral oedema who undergo decompressive craniectomy to relieve increased intracranial pressure. Hallmark of SSFS is the sinking of the scalp to a plane lower than the edges of the skull defect in the setting of neurological deterioration. Our objective is to report that SSFS can present after small craniotomy without cerebral cortex compression and to share our diagnostic/therapeutic approach. A 62-year-old woman with a glioblastoma developed SSFS after a small craniectomy and tumour resection without cerebral cortex compression but a decrease in the surgical cavity volume. Brain MRI showed decreased size of the surgical cavity. Interestingly, the patient also developed posterior reversible encephalopathy syndrome (PRES). This case highlights an atypical presentation of SSFS and the possible association with PRES. It also illustrates how an early cranioplasty can successfully reverse SSFS.
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Affiliation(s)
| | - Sheetal Shroff
- Department of Neuro-oncology, MDACC, Houston, Texas, USA
| | | | | | - Mark R Gilbert
- Department of Neuro-oncology, MDACC, Houston, Texas, USA
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Gertsch EA, Ullrich NJ. Seizures in children treated for a primary brain tumor: risk factors, evaluation and management. FUTURE NEUROLOGY 2014. [DOI: 10.2217/fnl.14.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT Seizures may be a presenting symptom of a brain tumor in childhood or can occur as a complication of treatment or subsequent effect occurring years after completion of therapy. Seizures create a number of therapeutic challenges and represent a significant comorbidity that results in decreased quality of life. Treatment options may be limited by interactions with chemotherapy and/or increased susceptibility to side effects. Moreover, seizures in this patient population may be less responsive to the traditional therapies typically effective for nontumor related epilepsy. While the pathophysiology of tumor-related epilepsy remains unclear, advances are being made in our understanding of the possible mechanisms involved. Newer anticonvulsants and improved diagnostic tools with refined surgical techniques show promise for future treatment approaches.
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Affiliation(s)
- Emily A Gertsch
- Department of Neurology, Boston Children‘s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Nicole J Ullrich
- Department of Neurology, Boston Children‘s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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