Neurologic Emergencies in the Patients With Cancer

Abstract

Neurologic complications of cancer are common and are frequently life-threatening events. Certain neurologic emergencies occur more frequently in the cancer population, specifically elevated intracranial pressure, epidural cord compression, status epilepticus, ischemic and hemorrhagic stroke, central nervous system infection, and treatment-associated neurologic dysfunction. These emergencies require early diagnosis and prompt treatment to ensure the best possible outcome and are best managed in the intensive care unit. This article reviews the presentation, pathophysiology, and management of the most common causes of acute neurologic decompensation in the patient with cancer.

Keywords: cord compression; elevated intracranial pressure; neuro-oncology; status epilepticus; stroke.

Figure 1

This is a patient with a meningioma. (A) shows the appearance of the meningioma on the T1 post-contrast sequence prior to stereotactic radiosurgery. (B) shows the enlargement of the contrast enhancing abnormality in the immediate period after stereotactic radiosurgery, as a consequence of pseudoprogression. (C) shows the associated vasogenic edema. (D) shows that the lesion has decreased cerebral blood volume on perfusion imaging, suggesting that the increase in contrast enhancement is due to treatment effect rather than tumor growth.

Figure 2

The histological appearance of radiation necrosis. The radiation necrosis is characterized by large zones of necrosis that primarily involves the white matter, and fibrinoid necrosis or hyalinization of blood vessels.

Figure 3

A large supratentorial lesion may cause uncal herniation, where the hippocampal gyrus is forced into the posterior fossa, resulting in compression of the midbrain and the ipsilateral third nerve. Uncal herniation may also cause Kernohan's notch phenomenon, where the contralateral corticospinal tract becomes compressed against the tentorium cerebelli as it passes through the midbrain. A large supratentorial mass may also result in midline shift and subfalcine herniation, which may cause a stroke in the ipsilateral anterior cerebral artery distribution. Finally, downward herniation can cause a pontine hemorrhage and herniation of the cerebellar tonsils, resulting in dysfunction of the medulla.

Figure 4

This is a patient with an anaplastic astrocytoma. (A) and (B) show the appearance of the patient's brain at presentation. (C) shows the effect of neoplastic infiltration on the patient's cerebellum, which results in compression of the brainstem, upward and downward herniation, and closure of the fourth ventricle. (D) shows the resultant hydrocephalus.

Figure 5

Treatment algorithm for adult convulsive status epilepticus at MSKCC.

Figure 5

Treatment algorithm for adult convulsive status epilepticus at MSKCC.

Figure 6

(A) through (C) are of a patient treated with fludarabine and (D) through (F) are of a patient treated with methotrexate. (A) and (D) are the fluid-attenuated inversion recovery (FLAIR) sequence, (B) and (E) are diffusion weighted imaging (DWI) sequences, and (C) and (F) are apparent diffusion coefficient (ADC) sequences.