What is the best approach to manage a patient with a history of resected frontal mass and radiation scarring who frequently puts themselves on the floor, potentially due to seizure activity or neurological instability?

Management of Frequent Self-Lowering to Floor in Post-Frontal Resection Patient with Radiation Scarring

This patient requires immediate evaluation for seizure activity with video-EEG monitoring, as frontal lobe lesions and radiation scarring create a highly epileptogenic substrate, and the behavior of "putting self on the floor" likely represents either atonic seizures, supplementary motor area (SMA) seizures with postural changes, or post-ictal states. 1, 2

Primary Diagnostic Considerations

Seizure-Related Etiologies (Most Likely)

• Frontal lobe seizures are the most probable cause given the history of resected frontal mass and radiation scarring, which creates an epileptogenic zone at the surgical margin and within radiation-damaged tissue 3

• SMA seizures specifically can manifest with postural changes and the urge to assume unusual positions, including lowering oneself to the ground, often without complete loss of consciousness 2

• Atonic seizures or drop attacks from frontal involvement can cause sudden loss of postural tone, leading patients to lower themselves preemptively to avoid injury 2

• The epileptogenic zone in frontal lobe surgery patients may be at or adjacent to the resection cavity, not necessarily within the original surgical target 2

Radiation-Related Complications

• Radiation necrosis should be considered, as it occurs in 5-25% of patients following radiation therapy and can present with new neurologic symptoms including seizures 4

• SMART syndrome (stroke-like migraine attacks after radiation therapy) can occur 2-10 years post-radiation and presents with focal neurological deficits and seizures, though this typically includes headache and focal deficits 1

• Radiation scarring creates cortical irritability that significantly increases seizure risk in the long term 3

Immediate Diagnostic Workup

Essential Investigations

• Video-EEG monitoring is mandatory to capture the episodes and determine if they represent seizure activity, as clinical observation alone cannot reliably distinguish frontal seizures from behavioral phenomena 2

• MRI with and without contrast using T2-weighted and FLAIR sequences to assess for:

  • Tumor recurrence at the resection site 3, 1
  • Radiation necrosis (look for cortical swelling and contrast enhancement, particularly in parieto-occipital regions) 4, 1
  • Progressive radiation-induced changes 1

• Assess for pre-ictal or post-ictal phenomena - patients may be experiencing auras or post-ictal confusion that prompts them to lower themselves to the floor as a protective mechanism 2

Critical Pitfall to Avoid

• Do not assume this is purely behavioral or psychiatric without ruling out seizure activity, as frontal lobe seizures can be subtle and may not present with classic convulsive movements 2

• Interictal EEG may be normal or show epileptiform discharges at or outside the SMA, so negative interictal findings do not exclude seizures 2

Management Algorithm

If Seizures Are Confirmed

1. Initiate or optimize antiepileptic therapy immediately, as patients with brain tumors and radiation scarring have a 15-20% seizure risk 5

2. Consider the epileptogenic zone location - subdural mapping data shows that in frontal seizure patients, the epileptogenic zone may be in high lateral frontal cortex or even precuneus, with rapid spread to SMA 2

3. Evaluate for surgical candidacy if seizures are medically refractory - three of four patients in one series achieved good seizure control with resection of the epileptogenic zone while preserving the SMA 2

If Radiation Necrosis Is Identified

• For symptomatic radiation necrosis, initiate high-dose dexamethasone with prolonged taper as first-line therapy 4

• If steroids fail or cause unacceptable side effects, proceed to bevacizumab 7.5 mg/kg every 3 weeks for two initial doses, with two additional doses if benefit is observed 4

• For refractory cases, consider surgical resection or laser interstitial thermal therapy (LITT) 4

• For asymptomatic radiation necrosis, observation is appropriate as progression often ceases spontaneously 4

If Tumor Recurrence Is Found

• Reassess treatment options including repeat resection, stereotactic radiosurgery, or systemic therapy depending on extent of disease and patient performance status 3

• Note that SMART syndrome patients may have concurrent tumor recurrence (three of four patients in one series), so both diagnoses can coexist 1

Safety Measures During Evaluation

• Implement fall precautions immediately to prevent injury during episodes 3

• Educate patient and caregivers about seizure precautions, including avoiding heights, operating machinery, or driving until diagnosis is established 6

• Consider empiric antiepileptic therapy during the diagnostic workup if episodes are frequent and concerning for seizures, particularly if video-EEG monitoring will be delayed 6

Prognostic Considerations

• Patients with larger total irradiated volumes and pre-existing neurologic symptoms have significantly higher odds of developing new-onset seizures (odds ratio 1.09 per 1-cm³ increase in volume and 3.08 for focal deficits, respectively) 6

• Good seizure control is achievable in most patients with appropriate identification and treatment of the epileptogenic zone 2

• The natural history of untreated complications in this population is poor, with median survival less than 2 months if tumor recurrence is present and untreated 5