Neurologic complications of bone marrow transplantation

Chemotherapy-induced peripheral neuropathy: A current review

Chemotherapy-induced peripheral neuropathy (CIPN) is a common dose-limiting side effect experienced by patients receiving treatment for cancer. Approximately 30 to 40% of patients treated with neurotoxic chemotherapy will develop CIPN, and there is considerable variability in its severity between patients. It is often sensory-predominant with pain and can lead to long-term morbidity in survivors. The prevalence and burden of CIPN late effects will likely increase as cancer survival rates continue to improve. In this review, we discuss the approach to peripheral neuropathy in patients with cancer and address the clinical phenotypes and pathomechanisms of specific neurotoxic chemotherapeutic agents. Ann Neurol 2017;81:772-781.

Electrodiagnosis in Cancer Rehabilitation

With numerous advancements in early detection and multimodal therapy, cancer has become a chronic disease. As the number of cancer survivors continues to increase, physiatrists and other neuromuscular disease specialists are more likely to encounter individuals with residual impairments, disabilities, and/or handicaps resulting from cancer or related treatments. The patient with cancer is especially prone to injury directed at the peripheral nervous system at multiple anatomic levels. Electrodiagnosis is an invaluable tool in the evaluation of neuromuscular disorders in this patient population.

Neuromuscular complications in cancer

Cancer is becoming a treatable and even often curable disease. The neuromuscular system can be affected by direct tumor invasion or metastasis, neuroendocrine, metabolic, dysimmune/inflammatory, infections and toxic as well as paraneoplastic conditions. Due to the nature of cancer treatment, which frequently is based on a DNA damaging mechanism, treatment related toxic side effects are frequent and the correct identification of the causative mechanism is necessary to initiate the proper treatment. The peripheral nervous system is conventionally divided into nerve roots, the proximal nerves and plexus, the peripheral nerves (mono- and polyneuropathies), the site of neuromuscular transmission and muscle. This review is based on the anatomic distribution of the peripheral nervous system, divided into cranial nerves (CN), motor neuron (MND), nerve roots, plexus, peripheral nerve, the neuromuscular junction and muscle. The various etiologies of neuromuscular complications - neoplastic, surgical and mechanic, toxic, metabolic, endocrine, and paraneoplastic/immune - are discussed separately for each part of the peripheral nervous system.

Analysis of seizure risk factors after allogeneic hematopoietic stem cell transplantation: a 8 case report and literature review

The clinical characteristics of patients with seizures after allogeneic hematopoietic stem cell transplantation (allo-HSCT) were analyzed. A total of 8 cases of seizures after allo-HSCT were investigated. Clinical data of these cases were studied retrospectively. Of 159 cases subjected to allo-HSCT, seizure occurred in 8 cases during 29-760 days after transplantation, median survival time was 46 days, and there were 6 cases of tonic-clonic seizure. The incidence of seizure after matched unrelated HSCT was higher than that after related HSCT (P=0.017). Of 7 cases treated with cyclosporine A (CsA), 4 cases obtained high blood levels of CsA. In addition, hyponatremia was diagnosed in 5 cases. Abnormal electroencephalogram and brain MRI findings were found in some cases. During 20 days after seizure, 2 cases died due to infection and graft-versus-host disease (GVHD), respectively. It was suggested that multiple factors are associated with seizures after allo-HSCT. Rapid identification and correction of the causative factors are very important to prevent permanent central nervous system damage and reduce the mortality.

Neurological complications of transplantation: part I: hematopoietic cell transplantation

Hematopoietic cell transplantation (HCT) is the preferred treatment for an expanding range of neoplastic and nonmalignant conditions. Increasing numbers of solid organ transplantations (SOTs) add an additional population of immunosuppressed patients with multiple potential neurological problems. While the spectrum of neurological complications varies with conditioning procedure and hematopoietic cell or solid organ source, major neurological complications occur with all transplantation procedures. This 2 part review emphasizes a practical consultative approach to central and peripheral nervous system problems related to HCT or SOT with clinical and neuroimaging examples from the authors' institutional experience with the following conditions: the diversity of manifestations of common infections such as varicella zoster virus, Aspergillus, and progressive multifocal leukoencephalopathy (PML), drug therapy-related complications, stroke mechanisms, the spectrum of graft versus host disease (GVHD), and neurologically important syndromes of immune reconstitution inflammatory syndrome (IRIS), posterior reversible encephalopathy syndrome (PRES), and posttransplantation lymphoproliferative disorder (PTLD). These complications preferentially occur at specific intervals after HCT and SOT, and neurological consultants must recognize an extensive spectrum of syndromes in order to effect timely diagnosis and expedite appropriate treatment.

Neurologic Complications of Bone Marrow and Stem-cell Transplantation in Patients with Cancer

Transplantation of bone marrow or peripheral blood stem cells is increasingly being used to treat a variety of oncologic disorders. These procedures are associated with a large spectrum of neurologic complications that significantly contribute to patient morbidity and mortality. These complications may arise at any time during and after the transplantation process and are particularly common in patients requiring chronic immunosuppression. The most frequent complications are infections and cerebrovascular or metabolic events, and toxicity from radiation or chemotherapy. Because of the unique circumstances and treatments involved in each step of the transplantation process, there is a higher incidence of some neurologic complications during discrete time periods, and an awareness of the temporal relationship of the neurologic disorder to the transplantation process facilitates diagnosis. With the exception of post-transplant lymphoproliferative disorder, in which reduced immunosuppression may be an effective therapeutic strategy, therapies are often the same as in the nontransplant patient. Complications of therapy can arise because of the presence of multiple comorbidities and medication interactions. Anticipation of common opportunistic infections and appropriate use of prophylactic medications can significantly reduce the incidence of infectious complications.

CNS complications in children receiving chemotherapy or hematopoietic stem cell transplantation: retrospective analysis and clinical study of survivors

BACKGROUND

Clinical studies analyzing CNS complications in pediatric oncology systematically are rare.

PROCEDURE

In a single center retrospective analysis, CNS complications in 950 subsequent pediatric patients treated between 1992 and 2004 by chemotherapy or hematopoietic stem cell transplantation (HSCT) were studied. Forty-six patients had pre-existing CNS diseases and were excluded. Out of the 904 remaining, 76 (8.4%) had 82 CNS complications.

RESULTS

The most common manifestations were seizures (in 50.6% of the CNS episodes), altered states of consciousness, and motor deficits (in 47.5% of the episodes each). CNS complications were caused by infections (26.8%), toxicity (25.6%), neoplasma (13.4%), vascular (10.9%), and metabolic disturbances (8.5%). In 14.6%, the mechanism remained unclear. Patients (23.7%) died from the CNS event. Neoplastic disorders had the worst (50%) while metabolic the best (0% mortality) prognosis. Imaging techniques were the most effective diagnostic measures, followed by laboratory analysis, clinical examination, and CSF analysis. A neuro-psychological (CBCL, CFT-1/-20-testing) examination could be done in 21 of 32 long-term survivors. Seven had a major, 3 minor neurological impairment, 11 were normal in all tests.

CONCLUSIONS

These data show that there is not one typical CNS complication, but a wide variety. There is no close connection between either underlying disease or symptoms and cause of the complication. Prognosis is variable. About two thirds of the long-term survivors could lead a normal life.

Chronic inflammatory demyelinating polyradiculoneuropathy in chronic graft-versus-host disease following allogeneic hematopoietic stem cell transplantation: case report

The chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an unusual but important complication of hematopoietic stem cell transplantation (HSCT) rarely reported to date. We describe a 17-year-old woman with a diagnosis of acute myeloid leukemia due to Fanconi's anemia who was submitted to allogeneic HSCT and developed CIDP as part of graft-versus-host disease. Investigation showed high cerebrospinal fluid protein; electrophysiological studies revealed sensory-motor demyelinating polyradiculoneuropathy; muscle and nerve biopsy were compatible with CIDP.

Neurologic complications of bone marrow, stem cell, and organ transplantation in patients with cancer

Bone marrow and peripheral blood stem cell transplantation are part of the standard of care for a variety of oncologic and non-oncologic disorders and are associated with a large spectrum of neurologic complications. These complications may arise at any time during and after the transplantation process, especially in subjects requiring chronic immunosuppression, and are most frequently related to infections, cerebrovascular or metabolic events, and toxicity from radiation or chemotherapy. Due to the unique circumstances and treatments surrounding each step in the transplantation process, there is a higher incidence of some neurologic complications during discrete time periods. Being aware of the temporal relationship of the neurologic disorder within the transplantation process can therefore facilitate diagnosis and institution of appropriate therapy. Neurologic complications after solid organ transplantation are often due to similar mechanisms as in patients after bone marrow and stem cell transplantation although there are several complications unique to these patients such as transmission of infectious agents by the donated organ. For these patients, the clinician needs to have a high index of suspicion that the neurologic problem is related to the transplant.

Complicaciones neurológicas después de un trasplante de progenitores hemopoyéticos. Estudio de 14 pacientes

BACKGROUND AND OBJECTIVE

The frequency and cause of neurologic complications (NC) following hematopoietic stem cell transplantation (HSCT) have changed over time. We have analyzed the NC in 185 consecutive patients who underwent HSCT in a period of 5 years in a single HSCT Unit.

PATIENTS AND METHOD

185 consecutive patients underwent HSCT (44 allogeneic) between February 2000 and March 2005 to treat hematologic malignancies. Most frequent diagnoses were multiple myeloma (41 patients) and acute myeloblastic leukemia (n = 35). Demographic and clinical data, HSCT characteristics and procedure-related events with special attention to neurological findings were recorded. Imaging studies (magnetic resonance imaging and/or computerized tomography scan), cerebro-spinal fluid analyses and microbiological studies were performed in all patients developing NC.

RESULTS

After a median follow-up of 27 months, 14 patients (7.5%) developed NC, 6 of them after an allogeneic HSCT. The most common conditioning regimen in these patients was BEAM (5/14); 6 patients submitted to allogenic-HSCT received methotrexate and cyclosporin as graft-versus-host disease prophylaxis, and intrathecal prophylaxis of relapse was administered to 3 patients. The median time to the appearance of a NC was 13 days from HSCT (range: -4 to + 135 days). Seizures (8 cases) and encephalopathy (n = 2) were the most frequent clinical manifestations. In 12 cases the cause of the NC was related to drugs, there was one case of viral encephalitis and in the remaining case was caused by hemorrhage. Two patients died, one due to thrombotic thrombocytopenic purpura attributed to cyclosporin and the other due to viral encephalitis.

CONCLUSIONS

In our series drug toxicity was the main cause of NC (particularly seizures) following HSCT. Our results contrast with previous studies in which infections, especially of fungal origin, were the main cause of NC. These changes over time should be taken into account during diagnostic procedures.

Incidence and etiology of cerebrovascular disease in patients with malignancy

Cerebrovascular disease is common in cancer patients and often arises from mechanisms unique to malignancy. Direct tumor effects include intratumoral hemorrhage, arterial and venous sinus invasion by tumor mass or leptomeningeal infiltrates, and tumor emboli. Complications of chemotherapy, radiation therapy, and hematopoietic stem-cell transplantion for cancer can occur before, during, or years after treatment. Coagulopathic conditions involve disseminated intravascular coagulation, thrombocytopenia, nonbacterial thrombotic endocarditis, and cerebral intravascular coagulation. Finally, septic infarction from fungal or bacterial sepsis and infectious vasculitis manifest in cancer patients immunocompromised by malignancy or cancer therapy. In many cases a combination of mechanisms is causative, and both hemorrhagic and ischemic stroke can occur simultaneously. Stroke type and mechanism, as well as the stage and pathology of the neoplasm, dictate proper management and help delineate prognosis.

The transplant recipient for nontransplant surgery

The transplant recipient has traded a life-threatening illness for a chronically immunosuppressed state. Subsequent anesthetic management for non-transplant surgical procedures may be challenging. The anesthesia provider must be aware of the degree of post-transplant organ dysfunction and alter anesthesia techniques accordingly. This article reviews the anesthetic concerns for patients who have undergone a variety of organ transplants.