Radiation leukoencephalopathy associated with moderate hydrocephalus: intracranial pressure monitoring and results of ventriculoperitoneal shunting

Abstract

Delayed neurological sequelae of radiotherapy have several manifestations; leukoencephalopathy is one of the most common. Pathogenetic relationships between radiation leukoencephalopathy and other findings of diffuse radiation injury (brain atrophy and progressive ventriculomegaly) are not well defined. Moreover, no guidelines have been established for the treatment of hydrocephalus when associated with radiation leukoencephalopathy. Our study reports intracranial pressure (ICP) monitoring in two patients with radiation leukoencephalopathy with moderate hydrocephalus. High intraventricular mean pressure and high peaks were found, and marked improvement of clinical status after shunting was achieved. This study, although restricted to only two patients, shows that ventriculoperitoneal shunting insertion is useful in radiation-induced hydrocephalus, when ICP monitoring detects high mean pressure. A hypothesis is advanced concerning radiation-induced hydrocephalus with high ICP, emphasizing periventricular astrocytosis and its connections with cerebral compliance.

Toxic non-resorptive internal hydrocephalus as a result of haemorrhagic ventriculitis during induction chemotherapy of Bcr-Abl positive acute lymphoblastic leukaemia

“…Patients with solid tumours and cerebral metastases dominate in reports on adults. Contrary to our case after intrathecal chemotherapy, and also brain irradiation, hydrocephalus is usually a longterm complication, occurring several months after completion of therapy [4][5][6]. Fibrosis of arachnoid granulations inhibiting CSF reabsorption is proposed as a mechanism of radiation-induced hydrocephalus [6].…”

Neuroimaging of Brain Tumors: Pseudoprogression, Pseudoresponse, and Delayed Effects of Chemotherapy and Radiation

“…Conservative estimates indicate an incidence ranging from 5 to 30% in patients undergoing radiation therapy alone, and higher rates are reported in patients receiving concurrent chemotherapy or a combination of whole brain radiation therapy (WBRT) and stereotactic radiosurgery (SRS). [33][34][35] The risk of radiation therapyinduced leukoencephalopathy has been well recognized in long-term survivors treated for metastatic disease from tumors outside the nervous system. 36 White matter disease usually develops several months to years after treatment and is frequently associated with some degree of cognitive impairment but can manifest as profound dementia in some individuals.…”

“…[36][37][38] In some patients, progressive white matter disease, brain atrophy, and ventriculomegaly are associated with symptoms of gait failure with frequent falls, cognitive impairment, and incontinence, resembling the core symptoms of normal pressure hydrocephalus. 2,34,35,[39][40][41][42][43] Injury to cerebral white matter (myelinated fiber tracts) can result in progressive spongiform vacuoles and gliosis. 33,36,44 In its most severe form, a necrotizing leukoencephalopathy may develop, which typically is seen in patients treated with combined radiation and chemotherapy.…”

Experimental concepts for toxicity prevention and tissue restoration after central nervous system irradiation

“…For example, one out of 7 patients with cognitive impairment at least 1.5 years after radiotherapy improved after 30 sessions of HBO [53]. Patients with leukencephalopathy and moderate hydrocephalus (diagnosed by intracranial pressure monitoring) might profit from ventriculoperitoneal shunt insertion [54]. Quality of life can be improved by supportive measures (cognitive training, rehabilitation, special education etc.)…”