1/
#ContinuumCase
A 67 yo man with a known, active cancer presents to the ED. His wife reports that he has had worsening headaches, forgetfulness, & confusion. Today, he was increasingly sleepy which triggered the presentation.
An MRI is ordered.
🤔🤔🤔 @ContinuumAAN @LyellJ
2/
Neurologic complications in cancer patients are tricky. They can be due to
✨Malignant lesions
✨Systemic complications of disease
✨Paraneoplastic disorders
✨Treatment Side effects
3/
You absolutely must have a systemic approach to these patients. I think the best framework for this is in this review by @holroyd_katie, Dan Rubin and Henrikas Vaitkevicius:
pubmed.ncbi.nlm.nih.gov/34619783/
4/
Reviewing his cancer treatment history which do you find?
5/
Cancer treatments can cause a wide variety of PNS/CNS complications ranging from Myasthenia Gravis to PML. This review is an excellent overview of some of the CNS complications of various anti-cancer treatments: insightsimaging.springeropen.com/articles/10.11…
Awesome table:
6/
Briefly, Rituximab may cause PRES and very, very rarely result in reactivation of JC Virus and cause PML.
pubmed.ncbi.nlm.nih.gov/25489887/
7/
Methotrexate is known to cause a diffuse acute or chronic leukoencephalopathy.
The acute presentation is often hours after treatment and presents with confusion and seizures.
Chronic confusion and worsening aphasia may also occur. See radiopaedia:
radiopaedia.org/articles/metho…
8/
Treatment for this includes rescue leucovorin, dextromethorphan and aminophylline.
9/
CAR T-cells can have a whole host of systemic complications and I am eagerly awaiting @pulmcrit’s chapter on @emcrit / @iBookCC
Generally, the most feared complication of this is diffuse cerebral edema.
A nice “practical” review: pubmed.ncbi.nlm.nih.gov/32503897/
10/
But, the lesion in this case?
Due to nivolumab!
Immune checkpoint inhibitors (ipilimumab, nivolumab ad prembrolizumab) may have a range of PNS/CNS adverse events.
One feature that is unique to ICIs is inducing a subcortical immune-mediated encephalitis👇
11/
Encephalitis typically falls into two categories for these patients:
📍focal encephalitis, which can include limbic encephalitis
🧠meningoencephalitis (presents with fever, headache, and inflammatory CSF).
Rarely ICIs can cause hypophysitis (particularly ipilimumab).
12/
It is hypothesized that the focal encephalitis may be an unmasking of a previously occult paraneoplastic encephalitis when the patient is exposed to the ICI. These cases are associated with a significantly worse prognosis.
More here:
pubmed.ncbi.nlm.nih.gov/33720308/
13/
Really not much is known about how to treat these patients. Usually the treatment is withholding the ICI and administering corticosteroids...other induction immunosuppression has also been tried.
14/
Recap, when approaching neurologic complications in cancer patients, think
♋️cancer itself?
💊 treatment side effect?
🦀paraneoplastic phenomenon?
Neuroradiology can be very helpful in addition to the time course and localization.
15/ To check out more awesome ways in which imaging offers a window into autoimmune, paraneoplastic, and neuro-rheumatologic brain pathology, this is a fantastic review by @Lamaaw27 and TCho @ContinuumAAN
journals.lww.com/continuum/Full…
Share this Scrolly Tale with your friends.
A Scrolly Tale is a new way to read Twitter threads with a more visually immersive experience.
Discover more beautiful Scrolly Tales like this.