Disclosures: Joseph T. Tessler, DO, MS: No financial relationships or conflicts of interest

Case Diagnosis: Cerebral radiation necrosis induced encephalopathy

Case Description: 28 year-old male with relapsing acute lymphocytic leukemia (ALL) and central nervous system (CNS) involvement resulting in whole brain radiotherapy was transported to the emergency department following an acute episode of aggression and seizure-like activity. The patient was agitated, unable to consistently follow commands, dependent for self care, and required assistance for ambulation, but had no focal neurological deficits.

Setting: Tertiary care hospital.Assessment/

Results: Extensive work-up including electroencephalogram, cerebrospinal fluid cytology, and virology studies was negative. Magnetic resonance imaging of the brain demonstrated multi-focal cytotoxic edema with greatest involvement in the inferior frontal lobes and anterior temporal lobes, as well as leukoencephalopathy in the temporal lobes favoring a diagnosis of cerebral radiation necrosis. The patient could not receive bevacizumab; however, his agitation improved after starting dronabinol, and therapy services focused on cognition, activities of daily living (ADLs), and communication. Upon discharge, he followed directions more consistently, ambulated independently, performed ADLs with moderate assistance, and had clearer speech.

Discussion: CNS involvement of ALL occurs in 7-15% of relapse patients. Cerebral radiation necrosis (CRN) frequently occurs after whole brain radiotherapy, with incidence rates of 14-50% depending on radiation dose and therapy duration. CRN typically presents 6 months after radiation with symptoms ranging from mild cognitive impairment to cerebral herniation. First-line treatment for CRN is corticosteroids. Bevacizumab, an anti-vascular endothelial growth factor antibody, has shown promise in reversing the size of cerebral necrotic lesions and reducing corticosteroid therapy. Additionally, short-term courses of dopaminergic stimulants may increase cognitive function.

Conclusion: The neurological manifestations and management of CRN are rarely discussed in Physiatry, yet rehabilitation providers can play a critical role in addressing the neurological and functional deficits caused by CRN. It is important to educate Physiatrists about CRN in order to optimize management and overall quality of life in this patient population.

Level of Evidence: Level IV

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/cerebral-radiation-necrosis-a-case-report/