Cerebral irradiation is an established therapeutic modality in the treatment of primary and metastatic brain tumors. It has become clear in the past two decades that one of the side effects of brain irradiation is leukoencephalopathy. Three phases of white matter disease following irradiation are recognized. The first is an acute reaction, in which confusion or transient worsening of preexisting neurologic deficits occurs during treatment. CT or MRI scans show mild diffuse changes in the white matter that have been attributed to edema. This syndrome is fully reversible. The next phase is the early delayed reaction, which occurs weeks to months after treatment and may involve a variety of neurobehavioral deficits, including somnolence, apathy, memory loss, or dementia. More extensive white matter changes can be seen on neuroimaging studies, and cerebral demyelination is the neuropathologic correlate. This syndrome is also reversible in most cases. The most ominous reaction is the late delayed reaction, which develops 6 months to 2 years after treatment and features a progressive dementia that is due to widespread demyelination and necrosis. Treatment for all these phases is supportive, although corticosteroids are often employed with variable efficacy.

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