Depression as component of post-cranial irradiation somnolence syndrome

Neuropsychiatric sequelae of brain radiation therapy: A review of modality, symptomatology, and treatment options

OBJECTIVE

Consultation-liaison psychiatrists frequently evaluate cancer patients with brain involvement, and brain irradiation is often a mainstay of treatment for this population. A comprehensive review of the neuropsychiatric effects of brain radiotherapy is lacking in the psychiatric literature. This review aims to provide an in depth discussion of existing literature with guidance about treatments for radiation-induced neurocognitive decline.

METHODS

Narrative synthesis of available published literature retrieved from PubMed and MEDLINE databases. Particular focus was given to neuropsychiatric manifestations after radiotherapy, dose-response relationships, differential effects of whole versus stereotactic regimens, and studies investigating possible pharmacological treatments.

RESULTS

Brain irradiation induces cognitive, mood, and other symptoms that evolve in a time-dependent manner and adversely affect quality of life. Available data implicates loss of hippocampal neurogenesis and repair in post-radiotherapy changes. Clinical factors affecting incidence of neuropsychiatric compromise include total radiation dose, whole brain radiation, among others. Efficacy of pharmacological interventions is mixed for certain agents (ie, methylphenidate) but promising for others (ie, memantine).

CONCLUSIONS

Neuropsychiatric consequences of brain irradiation are common. Although our understanding of clinical manifestations and pathogenesis has advanced considerably, treatment options are poorly researched and use of any psychopharmacological intervention should therefore be tailored to individual patient needs.

Comprehensive assessment of Somnolence Syndrome in patients undergoing radiation to the brain

AIM

The aim of this prospective study was to assess Somnolence Syndrome (SS) in patients undergoing radiation to the brain.

BACKGROUND

SS is one of the sequelae of radiation to the brain, which is observed within three months of radiation. This is a self-limiting condition and a failure to diagnose leads to unnecessary investigations. This study was undertaken to objectively and subjectively analyze the occurrence, clinical presentation and severity of SS.

MATERIALS AND METHODS

Thirty-three patients receiving radiation to the brain were included in the study. Visual Analog Scale (VAS) was used for subjective assessment and the Littman Somnolence Syndrome (LSS) scale was used for objective assessment of SS. Sleep Latency Test (SLT) was used to quantify SS.

RESULTS

VAS scores showed an initial fall until week 3, followed by a plateau and a sudden increase after week 10. LSS scale at week 11 and 12 showed that 13 patients (43.3%) had grade 2, 5 (16.7%) had grade 3; and 2 (6.7%) had grade 4 SS. SLT revealed a shift of predominant sleep pattern from NREM 1 to NREM 2 at 6 weeks after radiation with a p value of 0.0412.

CONCLUSIONS

An insight into SS, its features, frequency of occurrence and self limiting nature can prevent anxiety and unwarranted investigations in the immediate post radiation period.

Somnolence syndrome in patients receiving radical radiotherapy for primary brain tumours: a prospective study

BACKGROUND AND PURPOSE

To characterise the incidence, pattern and severity of post cranial radiotherapy somnolence and to identify factors predictive of frequency and severity.

MATERIALS AND METHODS

Seventy consecutive patients receiving radical cranial irradiation were prospectively assessed for somnolence at baseline, during and up to 10weeks following radiotherapy using five variables scored on a visual analogue scale (VAS) and the Littman scale. Fatigue was measured using the FACT-G score and quality of life using the EORTC QLQC30+3 with the brain tumour module questionnaire.

RESULTS

Ninety percent of patients experienced ⩾grade 1 somnolence (Littman score) and this correlated with VAS scores (r=0.456, p<0.001). The score increased from 3 to 12weeks (p<0.001) with a peak at the end of treatment and improvement 6weeks later. None of the patient, disease or treatment characteristics analysed were predictive for the development or the severity of somnolence.

CONCLUSIONS

The majority of patients experience some degree of somnolence following radical radiotherapy for primary brain tumour and this follows a clear pattern during and after treatment. While there are no clear predictors of severity, the pattern described allows for provision of information for patients and carers to minimise the distress the syndrome may cause.

Somnolence syndrome and fever in pediatric patients with cranial irradiation

BACKGROUND

During initial treatments, pediatric cancer patients are frequently hospitalized for fever, which may be due to neutropenia or a manifestation of the somnolence syndrome (SS) after cranial radiation therapy (CRT). This was a retrospective chart review of patients who received CRT for central nervous system prophylaxis or treatment in acute lymphoblastic leukemia or lymphoma.

OBSERVATIONS

Of 21 patients, 15 (71%) developed SS; 10 were hospitalized for fever. Comparing somnolent and nonsomnolent patients, there was no statistically significant difference in the admission absolute neutrophil count; radiation dose, fraction, or duration; and time between completion of CRT and first hospitalization.

CONCLUSIONS

In postradiation phase, patients with SS are more likely to get fever leading to hospital admission regardless of ANC.

Radiation somnolence syndrome

Although initially described 7 decades ago, somnolence syndrome remains a poorly understood subacute effect of cranial irradiation. Despite the relatively transient and benign nature of somnolence syndrome, its symptoms can be distressing for children and caregivers. Anticipatory guidance related to radiation-induced somnolence remains a critical nursing intervention. This article reviews what is known about somnolence syndrome, including its causes, symptoms, and management.

Patients' experiences following cranial radiotherapy: a study of the somnolence syndrome

The aim of this study was to establish whether somnolence syndrome existed in adults by exploring their experiences after receiving cranial radiotherapy. Somnolence syndrome is described as excessive sleep, drowsiness, lethargy and anorexia and was found to occur in these patients. A description of the phenomenon was drawn from triangulation of the data. For 6 weeks following radiotherapy, the participants completed a diary consisting of two elements, a quantitative visual analogue scale and an open diary. This was followed by a qualitative semi-structured interview. Patients experienced sleepiness which they described as 'exhausted doing nothing' and that any activity was a 'struggle'. Some individuals described sensory changes, deafness and an increase in leg and arm weakness. These experiences presented a series of unexpected changes in their health which resulted in fear of treatment failure and disease recurrence. The study suggests that more information should be provided for patients on the side-effects that occur after radiotherapy has finished. Somnolence syndrome presented for the participants an experience which is not adequately described in previous literature. The nurse has an important role in providing information to prepare patients for their experience and more knowledge about this phenomenon is required for these patients to be informed adequately.