61 year old female presented with chief complaints of headache for 30 days, fever for 10 days, altered behavior for 10 days and convulsion for 2 days. She was diagnosed and treated as a case of carcinoma of left breast 5 years ago. MRI brain showed a lobulated lesion in the left frontal lobe. She came to our hospital for whole brain radiation as a diagnosed case of carcinoma of breast with brain metastasis. Review of MRI brain scan, revealed metastasis or query infective pathology. MR spectroscopy of the lesion revealed choline: creatinine and choline: NAA (N-Acetylaspartate) ratios of ∼1.6 and 1.5 respectively with the presence of lactate within the lesion suggestive of infective pathology. She underwent left fronto temporal craniotomy and evacuation of abscess and subdural empyema. Gram stain showed gram positive cocci. After 1 month of evacuation and treatment she was fine. This case suggested a note of caution in every case of a rapidly evolving space-occupying lesion independent of the patient's previous history.

Whole-brain radiation therapy has been the standard form of treatment for advanced cancers, metastatic to the brain. It has the advantage of easy availability and delivery, and effectiveness in offering relief from symptoms for many suitable patients. Since most of these patients have poor outcomes and limited survival, oncologists in the past had a nihilistic approach and as a result, the potential toxicities emerging from WBRT have been largely neglected. With advances been made in neurosurgery, imaging, medical and radiation oncology, the results for many patients have improved significantly, particularly for those having favorable prognostic factors. Hence, the use of WBRT has come under scrutiny, due to its potential effect on the neurocognitive functions of the patient and their quality of life. This review article attempts to investigate if the various Neurocognitive sparing radiotherapy procedures can become a standard radiotherapy method for selected patients receiving whole brain radiotherapy for metastatic disease.