What are the neurooncological (neuro-oncology) emergencies?

From the Guidelines

Neurooncological emergencies, such as spinal cord compression, require immediate medical attention to prevent permanent neurological damage, and the most effective approach involves a multidisciplinary team, including neurosurgery, radiation oncology, and medical oncology, as recommended by the Dutch national guideline on metastases and hematological malignancies localized within the spine 1. The management of neurooncological emergencies should prioritize the prevention of morbidity, mortality, and improvement of quality of life. Some key points to consider in the management of these emergencies include:

• Spinal cord compression requires urgent MRI imaging and high-dose dexamethasone (16mg daily in divided doses), followed by radiation therapy or surgical decompression within 24-48 hours to prevent permanent neurological damage.
• The use of antiepileptic drugs (AEDs) in patients with brain tumors should be judicious, as they can have significant side effects, and the potential benefits may not outweigh the risks, as suggested by the Society for Neuro-Oncology (SNO) and the European Association of Neuro-Oncology (EANO) guidelines on anticonvulsant prophylaxis in patients with newly diagnosed brain tumors 1.
• A multidisciplinary approach to care, including neurosurgery, radiation oncology, and medical oncology, is essential in the management of neurooncological emergencies, as recommended by the Congress of Neurological Surgeons (CNS) guidelines on the treatment and care of adults with metastatic brain tumors, endorsed by the American Society of Clinical Oncology (ASCO) and the Society for Neuro-Oncology (SNO) 1.
• Patients with known brain tumors should be educated about warning signs requiring immediate medical attention, including severe headache, vomiting, altered mental status, new-onset seizures, or rapidly progressing weakness, to ensure early recognition and treatment of neurooncological emergencies. The most recent and highest quality study on this topic is the 2021 guideline update on anticonvulsant prophylaxis in patients with newly diagnosed brain tumors by the Society for Neuro-Oncology (SNO) and the European Association of Neuro-Oncology (EANO) 1, which provides evidence-based recommendations for the management of seizures in patients with brain tumors. In terms of specific treatments, the use of dexamethasone, mannitol, and hyperventilation may be effective in managing increased intracranial pressure, while benzodiazepines such as lorazepam or diazepam, followed by maintenance antiepileptic drugs like levetiracetam, may be used to manage seizures, as suggested by the guidelines on the management of brain tumor-related emergencies 1. Overall, the management of neurooncological emergencies requires a multidisciplinary approach, prompt recognition and treatment, and a focus on preventing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

Dexamethasone sodium phosphate injection is generally administered initially in a dosage of 10 mg intravenously followed by four mg every six hours intramuscularly until the symptoms of cerebral edema subside Response is usually noted within 12 to 24 hours and dosage may be reduced after two to four days and gradually discontinued over a period of five to seven days. For palliative management of patients with recurrent or inoperable brain tumors, maintenance therapy with two mg two or three times a day may be effective

The treatment of cerebral edema in neurooncological emergencies with dexamethasone involves an initial dose of 10 mg intravenously, followed by 4 mg every 6 hours intramuscularly.

• The response to treatment is usually seen within 12 to 24 hours.
• The dosage can be reduced after 2 to 4 days and gradually discontinued over 5 to 7 days.
• For patients with recurrent or inoperable brain tumors, a maintenance therapy of 2 mg two or three times a day may be effective 2.

From the Research

Neuro-oncologic Emergencies

• Neuro-oncologic emergencies are life-threatening conditions that require immediate attention and multi-disciplinary care 3, 4.
• These emergencies can be caused by the tumor's direct effects on the nervous system, such as cerebral edema, increased intracranial pressure, seizures, spinal cord compression, and leptomeningeal metastases 3.
• They can also be caused by systemic complications, such as thrombocytopenia, coagulopathy, hyperviscosity syndromes, infection, immune-related disorders, and adverse effects of treatment 3.

Common Neuro-oncologic Emergencies

• Intracranial hypertension and brain herniation are common complications in patients with brain tumors 4, 5.
• Spinal cord compression is another common emergency that requires immediate attention 4, 6.
• Seizures and leptomeningeal metastases are also frequent neuro-oncologic emergencies 3, 5.

Management and Treatment

• Timely intervention is crucial to prolong survival and improve quality of life in patients with neuro-oncologic emergencies 3.
• Treatment strategies include general measures, medical interventions, and surgery, depending on the specific emergency and the patient's condition 4, 7.
• Critical care management is essential in patients with cerebral edema and increased intracranial pressure, and may involve monitoring in the intensive care unit 7.