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Case Report
 
Recurrent stroke after low dose whole brain radiotherapy for brain metastases of breast cancer
Hanneke JM Meijer1, Lucille DA Dorresteijn2, Dominic AX Schinagl1, Hanneke WM van Laarhoven3
1Department of Radiation Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
2Department of Neurology, Medisch Spectrum Twente, Enschede, The Netherlands.
3Department of Medical Oncology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.

doi: 10.5348/ijcri-2014-01-434-CR-7

Address correspondence to:
Dominic A.X. Schinagl
MD, Radboud University Nijmegen Medical Centre, Department of Radiation Oncology (874)
P.O. Box 9101, 6500 HB Nijmegen
The Netherlands
Phone: +31-24-3614515
Fax: +31-24-3610792
Email: d.schinagl@rther.umcn.nl

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How to cite this article:
Meijer HJM, Dorresteijn LDA, Schinagl DAX, van Laarhoven HWM. Recurrent stroke after low dose whole brain radiotherapy for brain metastases of breast cancer. International Journal of Case Reports and Images 2014;5(1):32–35.


Abstract
Introduction: Patients with cerebral metastases from breast cancer have a very limited prognosis. Whole brain radiotherapy is a treatment option for these patients. Cranial irradiation can cause cerebrovascular disease years after treatment, but this is unusual in adults when only a low total dose is given. Furthermore, in most patients, survival is too short to develop cerebrovascular disease.
Case Report: A 35-year-old woman diagnosed with breast cancer, developed pulmonary and cerebral metastases after initial treatment. After whole brain radiotherapy to a dose of 20 Gy in 4-Gy-fractions, followed by chemotherapy, she was in complete remission. After 20 years, she developed a stroke. Magnetic resonance imaging scan of the brain showed an ischemic lesion consistent with small vessel disease and also diffuse white matter injury. This is an atypical location for regular vascular disease, but it may be involved after cranial irradiation. Her hypertension was adequately treated. The patient lost weight and started with acetylsalicylic acid, dipyridamole and simvastatin. Despite these preventive measures, she had two more strokes within 18 months. Magnetic resonance imaging scan of the brain again showed ischemic lesions, consistent with small vessel disease. Her breast cancer remains in complete remission.
Conclusion: This case describes an extraordinary long survival in a patient with breast cancer and visceral metastases. It shows that low dose cranial irradiation may contribute to intracerebral vasculopathy. Lifestyle interventions and regular checkups for risk factors of cardiovascular disease might be in place for patients with a long survival after cranial irradiation.

Keywords: Recurrent stroke, Breast cancer, Whole brain radiotherapy (WBRT), Cerebrovascular disease, Stereotactic radiosurgery (SRS), Karnofsky performance score, Cranial irradiation


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Author Contributions
Hanneke JM Meijer – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Lucille DA Dorresteijn – Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Dominic AX Schinagl – Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Hanneke WM van Laarhoven – Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
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The corresponding author is the guarantor of submission.
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Conflict of interest
Authors declare no conflict of interest.
Copyright
© Hanneke JM Meijer et al. 2014; This article is distributed the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any means provided the original authors and original publisher are properly credited. (Please see Copyright Policy for more information.)