Early central nervous system complications after reduced-intensity stem cell transplantation

Abstract

To investigate clinical characteristics of early central nervous system (CNS) complications after reduced-intensity stem cell transplantation (RIST), we reviewed the medical records of 232 patients who had undergone RIST for hematologic diseases at our institutions between September 1999 and June 2003. All patients had received purine analog-based preparative regimens. Stem cell sources comprised granulocyte colony-stimulating factor-mobilized blood from HLA-identical or 1 locus-mismatched related donors (n = 151), unrelated bone marrow (n = 44), or unrelated cord blood (n = 37). Graft-versus-host disease prophylaxis incorporated cyclosporine with or without methotrexate. Diagnosis of CNS complications was based on clinical, radiologic, and microbiological findings. CNS complications occurred in 18 patients (7.8%), with a median onset of 22 days, and were infectious (n = 1), metabolic (n = 15), or cerebrovascular (n = 2). Symptoms included seizures (n = 7), visual disturbance (n = 2), headache (n = 8), nausea (n = 8), vomiting (n = 6), impaired consciousness (n = 16), and hemiparesis (n = 3). Complications improved promptly in 10 patients, and 8 patients died without improvement within 30 days. Multivariate analysis with logistic regression identified umbilical cord blood transplantation as a significant risk factor for early CNS complications (odds ratio, 14.5; 95% confidence interval, 3.7-56.9; P <.0001). CNS complications are a significant problem after RIST, particularly with umbilical cord blood. Limbic encephalopathy is an unrecognized subtype of neurotoxicity after umbilical cord blood transplantation.

Clinical Management of Posterior Reversible Encephalopathy Syndrome after Allogeneic Hematopoietic Stem Cell Transplantation: A Case Series and Review of the Literature

“…For alloHSCT, an overall incidence of PRES of 1.6-7.2% has been reported [20,21,22], and its occurrence might be influenced by the conditioning regimen [22], and underlying hematological malignancies [23], as well as the HLA match and the stem cell source [20,24]. Like other central nervous system complications after alloHSCT, PRES has been associated with increased morbidity and therapy-related mortality [21,25,26,27,28].…”

Central Diabetes Insipidus in an HHV6 Encephalitis Patient with a Posterior Pituitary Lesion that Developed after Tandem Cord Blood Transplantation

“…According to a number of previous reports, HHV6 exhibits high tropism, especially to the hippocampus, and the resulting lesions cause representative manifestations, including short-term memory loss and disorientation. HHV6 ubiquitously infects the central nervous system, in addition to the limbic system, and induces varied symptoms such as seizures, visual disturbances, headaches, nausea, vomiting, impaired consciousness, hemiparesis and tachycardia (7,9). Abnormal findings on laboratory examinations, including hypo-and hypernatremia, in patients after HSCT have been reported, in addition to the symptoms described above.…”

“…Previous research has shown that a reactivation of HHV6 occurs more frequently in patients undergoing cord blood transplantation (CBT) than in those undergoing other types of hematopoietic stem cell transplantation (HSCT), including bone marrow transplantation and peripheral blood stem cell transplantation (6). CBT is also a significant risk factor for early central nervous system complications following reduced intensity stem cell transplantation (7). As the number of CBTs is increasing, it is likely that more cases of HHV6 infection will occur, including cases with unusual symptoms.…”

Posterior Reversible Encephalopathy Syndrome

“…80,83,98 Even higher incidences (approximately 16%) have been reported using higher dose myeloablative regimens, in contrast to a PRES incidence of only 3% when nonmyeloablative preconditioning was used. 81,98 As higher incidence of graft versus host disease (GVHD) has been identified in patients developing PRES, GVHD effects have been suggested to play a role in the pathogenesis of PRES. 84,[99][100][101] In solid organ transplantation, PRES incidence has been reported to vary between 0.4% and 6%.…”

“…79 No specific lesion distribution patterns have been associated with this condition, however, a trend toward more frequent involvement of the basal ganglia and a significantly higher number of involved brain regions have been observed in PRES in the setting of preeclampsia-eclampsia, as compared to other underlying conditions. 32 PRES has been frequently described in the setting of allo-BMT or stem cell transplantation, 2,18,[80][81][82][83][84] as well as after solid organ transplantation, [85][86][87][88][89][90][91][92][93][94][95][96][97] mostly in connection with cyclosporine or tacrolimus neurotoxicity. PRES occurs most commonly in the first month after allo-BMT, the remaining cases usually within 1 year after transplantation.…”