Acute complications of cranial irradiation
- Ari Ballonoff, MD
Ari Ballonoff, MD
- Attending Radiation Oncologist
- Colorado Permanente Medical Group
- Exempla Saint Joseph Hospital
- Brian Kavanagh, MD, MPH
Brian Kavanagh, MD, MPH
- Section Editor — Radiation Therapy
- Professor and Vice-Chair
- Department of Radiation Oncology
- University of Colorado
Cranial irradiation is used to treat patients with primary or metastatic brain tumors and as prophylaxis for selected patients at high risk of neoplastic involvement of the nervous system. A full understanding of the potential consequences associated with cranial irradiation is needed both to manage potential complications and to properly counsel patients and/or families prior to treatment.
The primary factors influencing the likelihood of developing complications include the volume of normal brain tissue treated, the total radiation dose, and the fractionation schedule. The likelihood of brain toxicity also increases in the young (ie, <5 years old) and the elderly and with use of concurrent or sequential chemotherapy. Poorly characterized genetic factors may also make certain individuals more susceptible to otherwise safe doses of radiation. (See "Delayed complications of cranial irradiation", section on 'Pathophysiology'.)
The complications of radiation therapy are usually divided into acute effects that can occur during radiation or up to six weeks afterwards, early-delayed effects that appear up to six months after radiation, and late effects that can develop six months or more after the completion of radiation. Unlike acute and early-delayed reactions that are usually reversible, late reactions are generally irreversible.
The acute complications of both standard fractionated cranial irradiation and stereotactic radiosurgery will be reviewed here. The late complications of cranial irradiation and complications of spinal cord and peripheral nerve irradiation are discussed elsewhere. (See "Delayed complications of cranial irradiation" and "Complications of spinal cord irradiation" and "Brachial plexus syndromes", section on 'Neoplastic and radiation-induced brachial plexopathy' and "Lumbosacral plexus syndromes", section on 'Radiation plexopathy'.)
STANDARD FRACTIONATED RADIATION
Acute side effects occurring during standard fractionated brain radiation using contemporary techniques are typically mild and manageable with basic supportive care. Some of the more common and uncommon toxicities are discussed below.
- Powell C, Guerrero D, Sardell S, et al. Somnolence syndrome in patients receiving radical radiotherapy for primary brain tumours: a prospective study. Radiother Oncol 2011; 100:131.
- Breitbart W, Alici Y. Psychostimulants for cancer-related fatigue. J Natl Compr Canc Netw 2010; 8:933.
- Butler JM Jr, Case LD, Atkins J, et al. A phase III, double-blind, placebo-controlled prospective randomized clinical trial of d-threo-methylphenidate HCl in brain tumor patients receiving radiation therapy. Int J Radiat Oncol Biol Phys 2007; 69:1496.
- Lawenda BD, Gagne HM, Gierga DP, et al. Permanent alopecia after cranial irradiation: dose-response relationship. Int J Radiat Oncol Biol Phys 2004; 60:879.
- Aguiar D, Pazo R, Durán I, et al. Toxic epidermal necrolysis in patients receiving anticonvulsants and cranial irradiation: a risk to consider. J Neurooncol 2004; 66:345.
- Hsiao YH, Hui RC, Wu T, et al. Genotype-phenotype association between HLA and carbamazepine-induced hypersensitivity reactions: strength and clinical correlations. J Dermatol Sci 2014; 73:101.
- Vern-Gross TZ, Kowal-Vern A. Erythema multiforme, Stevens Johnson syndrome, and toxic epidermal necrolysis syndrome in patients undergoing radiation therapy: a literature review. Am J Clin Oncol 2014; 37:506.
- Glantz MJ, Cole BF, Forsyth PA, et al. Practice parameter: anticonvulsant prophylaxis in patients with newly diagnosed brain tumors. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000; 54:1886.
- Phillips P, Delattre JY, Berger C. Early and progressive increases in regional brain capillary permeability following single and fractionated dose cranial radiation in the rat. Neurology1987; 37:301 (Abstract).
- Evans ML, Graham MM, Mahler PA, Rasey JS. Use of steroids to suppress vascular response to radiation. Int J Radiat Oncol Biol Phys 1987; 13:563.
- DeAngelis LM, Posner JB. Neurologic Complications of Cancer, 2nd, Oxford University Press, 2008. p.163.
- Jereczek-Fossa BA, Zarowski A, Milani F, Orecchia R. Radiotherapy-induced ear toxicity. Cancer Treat Rev 2003; 29:417.
- Cairncross JG, Salmon J, Kim JH, Posner JB. Acute parotitis and hyperamylasemia following whole-brain radiation therapy. Ann Neurol 1980; 7:385.
- Young DF, Posner JB, Chu F, Nisce L. Rapid-course radiation therapy of cerebral metastases: results and complications. Cancer 1974; 34:1069.
- Armstrong C, Ruffer J, Corn B, et al. Biphasic patterns of memory deficits following moderate-dose partial-brain irradiation: neuropsychologic outcome and proposed mechanisms. J Clin Oncol 1995; 13:2263.
- Armstrong CL, Corn BW, Ruffer JE, et al. Radiotherapeutic effects on brain function: double dissociation of memory systems. Neuropsychiatry Neuropsychol Behav Neurol 2000; 13:101.
- Ryan J. Radiation somnolence syndrome. J Pediatr Oncol Nurs 2000; 17:50.
- Freeman JE, Johnston PG, Voke JM. Somnolence after prophylactic cranial irradiation in children with acute lymphoblastic leukaemia. Br Med J 1973; 4:523.
- Berg RA, Ch'ien LT, Lancaster W, et al. Neuropsychological sequelae of postradiation somnolence syndrome. J Dev Behav Pediatr 1983; 4:103.
- Mandell LR, Walker RW, Steinherz P, Fuks Z. Reduced incidence of the somnolence syndrome in leukemic children with steroid coverage during prophylactic cranial radiation therapy. Results of a pilot study. Cancer 1989; 63:1975.
- Uzal D, Ozyar E, Hayran M, et al. Reduced incidence of the somnolence syndrome after prophylactic cranial irradiation in children with acute lymphoblastic leukemia. Radiother Oncol 1998; 48:29.
- Shaw E, Scott C, Souhami L, et al. Radiosurgery for the treatment of previously irradiated recurrent primary brain tumors and brain metastases: initial report of radiation therapy oncology group protocol (90-05). Int J Radiat Oncol Biol Phys 1996; 34:647.
- Shaw E, Scott C, Souhami L, et al. Single dose radiosurgical treatment of recurrent previously irradiated primary brain tumors and brain metastases: final report of RTOG protocol 90-05. Int J Radiat Oncol Biol Phys 2000; 47:291.
- Chin LS, Lazio BE, Biggins T, Amin P. Acute complications following gamma knife radiosurgery are rare. Surg Neurol 2000; 53:498.
- Gelblum DY, Lee H, Bilsky M, et al. Radiographic findings and morbidity in patients treated with stereotactic radiosurgery. Int J Radiat Oncol Biol Phys 1998; 42:391.
- Salek MA, Karlsson B, Yeo TT, et al. Lethal intratumoral haemorrhages of brain metastases during radiosurgery: case reports and literature review. Acta Neurochir (Wien) 2013; 155:115.
- Werner-Wasik M, Rudoler S, Preston PE, et al. Immediate side effects of stereotactic radiotherapy and radiosurgery. Int J Radiat Oncol Biol Phys 1999; 43:299.
- Murphy MJ, Chang SD, Gibbs IC, et al. Patterns of patient movement during frameless image-guided radiosurgery. Int J Radiat Oncol Biol Phys 2003; 55:1400.
- Takeuchi H, Yoshida M, Kubota T, et al. Frameless stereotactic radiosurgery with mobile CT, mask immobilization and micro-multileaf collimators. Minim Invasive Neurosurg 2003; 46:82.
- Kamath R, Ryken TC, Meeks SL, et al. Initial clinical experience with frameless radiosurgery for patients with intracranial metastases. Int J Radiat Oncol Biol Phys 2005; 61:1467.
- STANDARD FRACTIONATED RADIATION
- Common acute reactions
- - Fatigue
- - Nausea and vomiting
- - Radiation dermatitis and alopecia
- - Cerebral edema
- Uncommon acute reactions
- - Hearing problems
- - Myelosuppression
- - Mucositis
- - Parotitis
- - Acute encephalopathy
- Early-delayed reactions
- - Transient focal neurologic symptoms
- - Pseudoprogression
- - Somnolence syndrome
- STEREOTACTIC RADIOSURGERY
- Severe acute reactions
- Less severe acute reactions
- INFORMATION FOR PATIENTS