Optimal Management of Brainstem Metastases

A Narrative Review

Joan Y. Lee; Danielle A. Cunningham; Erin S. Murphy; Samuel T. Chao; John H. Suh


Chin Clin Oncol. 2022;11(2):15 

In This Article

Symptom Management

Currently, SRS is the definitive mode of alleviating symptomatic brainstem metastasis.

Chen and colleagues reported a 55% symptom improvement rate in 323 patients across 13 studies.[7] Some clinical manifestations of brainstem metastasis may require management in the interim before radiosurgery. Corticosteroids and anti-epileptic drugs (AEDs) are the mainstays of symptomatic management of brain metastasis, though some patients may require a shunt. The Congress of Neurological Surgeons Evidence-Based Guidelines recommend starting 4 to 8 mg/d of dexamethasone for mild symptoms of elevated intracranial pressure and peritumoral edema secondary to brain metastases and higher doses such as 16 mg/d for severe symptoms.[26] In patients with impaired consciousness or other severe signs of elevated intracranial pressure, Sawaya and colleagues report that headache and neurologic deficits may respond to corticosteroids within 1 day and full effect within 48 hours.[27] Steroid doses should be tapered as soon as possible as tolerated to minimize adverse effects of long-term corticosteroid use. The benefits and harms of corticosteroid use must be carefully considered if used concurrently with immune checkpoint inhibitors. Baseline corticosteroid use of ≥10 mg of prednisone equivalent has been associated with inferior outcomes in patients with non-small-cell lung cancer (NSCLC) treated with PD-(L)1 blockade.[28,29]

Brainstem seizures are generally rare, brief episodes (15–60 seconds) of sensory and motor disturbance with a tonic-algetic and akinetic-atonic pattern without loss of consciousness. Electroencephalogram (EEG) typically demonstrates a normal pattern with occasional, transient decreases of amplitude. Carbamazepine, valproic acid, and phenytoin are effective AEDs for brainstem seizures.[30]