Updated on 29/01/2025
The title of Fiona M McKevitt’s article in the February 2023 issue of Practical Neurology caught my attention: “What Can a Neurologist Do for Neuro-Oncology Patients?” Neuro-oncology is a branch of medicine focused on managing central nervous system tumors and the neurological complications of systemic cancers. Neurologists can play a key role, alongside other disciplines, in the management of patients with brain tumors.
Photo: Altan Akay
Headache is the most common initial symptom in patients diagnosed with glioma. It occurs in 23.5% of cases and rises to 46.5% among patients presenting to the hospital. In addition to headaches, most patients may experience focal or non-focal symptoms (e.g., confusion, cognitive, and personality changes). Less than 2% of patients present without any other symptoms or signs. Depending on the tumor's location, symptoms such as speech and vision impairments or paralysis may also occur. Seizures are common among individuals with brain tumors. Between 20-40% of all brain tumor patients experience seizures before diagnosis, and 20-48% have seizures after the diagnosis. Following diagnosis, patient management is coordinated with medical oncology and neurosurgery. Neurologists also play a role in decisions regarding corticosteroid treatment and initiating antiepileptic drugs.
Patients with brain tumors often receive corticosteroid treatment to reduce tumor-associated edema. However, several questions need to be answered before initiating therapy: Does the patient need this treatment? Will corticosteroids interfere with the diagnosis? What is the optimal dosage? How long should the treatment continue? For instance, if the tumor has no mass effect, treatment may not be necessary. Additionally, in cases where central nervous system lymphoma is suspected, corticosteroid therapy may reduce the diagnostic yield of a biopsy.
Treatments for both central nervous system and systemic cancers can cause neurological complications.
1. Neurological Complications of Radiotherapy:
Radiation therapy to the brain can lead to both early and late complications. Early side effects include nausea, hair loss, and seizures. Late complications may begin 6-12 months after treatment but can take years to manifest. These include neurocognitive effects, radiation-induced vasculopathy, SMART syndrome (stroke-like migraine attacks after radiation therapy), and radionecrosis.
2. Neurological Complications of Chemotherapy:
3. Neurological Complications of Immunotherapies:
The term immunotherapy encompasses a wide range of cancer treatments, including monoclonal antibodies (e.g., rituximab, cetuximab), immune checkpoint inhibitors (e.g., pembrolizumab, ipilimumab, nivolumab), cancer vaccines (e.g., talimogene laherparepvec), cytokines (e.g., interferon-alpha, aldesleukin), and chimeric antigen receptor T-cell (CAR-T) therapies. As these treatments become more widespread, their neurological side effects are becoming better understood.
Patients with brain tumors require a multidisciplinary approach involving neurologists, neurosurgeons, neuroradiologists, neuropathologists, neuropsychologists, oncologists, neurorehabilitation specialists, clinical nurse specialists, and allied healthcare professionals. Neurologists also evaluate patients undergoing systemic cancer treatments who develop neurological side effects. Advances and intensified treatments are leading to longer survival times, making the neurological complications of brain tumor and systemic cancer therapies increasingly prevalent.
