Continuum: Lifelong Learning in Neurology

Purpose of Review: Patients with brain tumors require close attention to medical issues resulting from their disease or its therapy. Effective medical management results in decreased morbidity and mortality and improved quality of life. The most frequent neurology-related issues that arise in these patients include seizures, peritumoral edema, venous thromboembolism, fatigue, and cognitive dysfunction. This article focuses on the most recent findings for the management of the most relevant medical complications among patients with brain tumors.Recent Findings: Increasing evidence suggests that anticoagulation in patients with thromboembolic complications is safe even when they are receiving antiangiogenic therapy. There are also increasing data to support the use of newer, non-enzyme-inducing antiepileptic drugs, which have the advantage of lacking interactions with antineoplastic agents and are as effective as their older counterparts at preventing seizures. Relatively few studies have addressed the management of fatigue and depression, and definitive recommendations cannot be made.Summary: Corticosteroids to treat vasogenic edema should be used at the minimum amount required to control symptoms and should be tapered as quickly as possible. Anticonvulsants should be used only if patients have had seizures. Non-enzyme-inducing antiepileptic drugs are preferred to minimize interactions with concurrently administered chemotherapy. Thromboembolic complications are common and are preferably treated with low-molecular-weight heparins. Only patients with hemorrhagic complications require an inferior vena cava filter. Cognitive deficits are frequent in patients with brain tumors and include problems such as poor short-term memory, distractibility, personality change, emotional lability, loss of executive function, and decreased psychomotor speed. Stimulants can help to improve these symptoms.(C) 2012 American Academy of Neurology

Purpose of Review: Spinal cord disease is not uncommon in patients with systemic cancer. Most cases are due to epidural tumor metastases with resulting cord compression, although intramedullary spinal cord metastases, radiation myelopathy, and myelopathic complications of chemotherapy must be considered.Recent Findings: Techniques for surgical decompression of the spinal cord in patients with epidural tumor have improved significantly over the past decade. Several studies have demonstrated improved neurologic outcome in a subset of patients with epidural spinal cord compression treated surgically.Summary: This article outlines the clinical features, radiographic findings, and differential diagnosis of spinal cord disease in patients with cancer and describes the therapeutic approach to these patients. Early identification and treatment of patients with epidural spinal cord compression is critical to maintaining neurologic function and preserving quality of life.(C) 2012 American Academy of Neurology

Purpose of Review: Radiation administered to treat CNS neoplasms or systemic cancers adjacent to the CNS can result in a variety of acute, subacute, and delayed clinical syndromes of the brain and spinal cord. Less commonly, the brachial or lumbosacral plexus or the cranial nerves are damaged by radiation therapy (RT). Cranial blood vessels can also be affected by brain RT, especially when it is administered during childhood and results in delayed vessel structural changes. These disorders are important because their presentation can mimic tumor recurrence. Knowledge of the classic clinical signs, imaging features, and time interval from RT will assist the practitioner in establishing the diagnosis and recommending treatment when appropriate.Recent Findings: The acute and subacute syndromes are temporary. An important subacute syndrome following focal external beam RT in combination with chemotherapy to treat newly diagnosed glioblastoma, termed pseudoprogression, has recently been characterized. In addition, recent clinical experience indicates that the delayed RT-induced CNS syndromes, once considered irreversible, can be treated effectively in some patients.Summary: Recent and ongoing research is lending new insights into the mechanisms of RT-related CNS injury and will hopefully lead to more effective methods for the prevention and treatment of this undesired, but typically unavoidable, complication of RT.(C) 2012 American Academy of Neurology

Purpose of Review: This article provides an update on classic paraneoplastic syndromes of the CNS and autoimmune encephalitis syndromes associated with antibodies against synaptic proteins, including the NMDA receptor, LGI1, and Caspr2, among others.Recent Findings: Most classic paraneoplastic syndromes are associated with antibodies against intracellular (onconeuronal) antigens, appear to be mediated by cytotoxic T-cell responses, and have limited response to treatment. The autoimmune synaptic disorders are associated with antibodies against extracellular epitopes, appear to be directly mediated by antibodies, and are responsive to immunotherapy. The syndromes associated with antibodies against intracellular antigens almost always occur in conjunction with cancer, and their clinical course is usually monophasic. In contrast, syndromes associated with antibodies against synaptic proteins may occur with or without cancer and often relapse.Summary: The spectrum of autoimmune disorders of the CNS with distinct clinical and immunologic associations is expanding. Prompt diagnosis and treatment can result in recovery from some syndromes.(C) 2012 American Academy of Neurology

Purpose of Review: This article reviews the current standard of care of astrocytic gliomas and primary CNS lymphoma and discusses promising new therapeutic targets.Recent Findings: Standard treatment modalities for primary malignant brain tumors include resection, radiation, local or systemic chemotherapy, and, most recently, antiangiogenic agents. However, these tumors often have a rapid course, and patients usually die within a few years of diagnosis. Improved surgical techniques and radiation and chemotherapy can prolong survival while maintaining quality of life, but these therapies remain inadequate.Summary: The care of patients with malignant brain tumors is challenging. A better understanding of the pathogenesis of primary malignant brain tumors and the elucidation of aberrant molecular pathways are leading to novel treatment strategies and the ability to identify patients who may benefit from specific treatments.(C) 2012 American Academy of Neurology

Outcomes for patients with glioblastoma have improved with the addition of temozolomide (TMZ) chemotherapy to radiation therapy followed by adjuvant TMZ for up to 1 year. Patients often wish to continue chemotherapy after the standard 1-year course. Whether to continue or to stop TMZ is a complex and stressful decision for the patient and family, and the decision should be based on a discussion of the known risks and benefits of each choice.(C) 2012 American Academy of Neurology