Abstract
INTRODUCTION: Treatment decisions for brain metastases balance potential benefits of tumor control, symptom alleviation, and survival, with the risk of functional impairment or reduced quality of life. Bilateral occipital metastases pose a risk of significant visual deficits and even cortical blindness, with an unclear rate of resolution and development of these debilitating symptoms following resection or radiotherapy. METHODS: We retrospectively reviewed all cases of bilateral occipital metastases treated with surgery and/or radiotherapy between 2008–2017 at the Brigham and Women’s Hospital. RESULTS: 18 patients with bilateral occipital metastases (median age 64 years; 13 women, 5 men) were identified. The most frequent primary cancer sites were lung (56%), melanoma (17%) and breast (11%). Visual symptoms were present in 67% of all cases, of which 67% had a visual filed deficit, 17% had diplopia, and 17% had an acuity deficit. These metastases were initially managed with resection (44%), radiotherapy (28%), or both (28%). In patients who initially presented with visual symptoms, 75% improved with treatment while 25% remained stable. In those who presented with no visual symptoms, 67% remained at baseline, 17% worsened acutely, and 17% worsened permanently with treatment. The majority of patients were also managed with post-treatment steroids. A representative case illustration is discussed of a patient who initially received whole brain radiation therapy (WBRT) for 10 days, with dexamethasone for the first 8 days of radiation. Upon completion of WBRT, the patient developed rapidly worsening visual acuity, which subsequently improved with bilateral occipital craniotomy for tumor resection. CONCLUSIONS: Patients with bilateral occipital metastases may present with visual symptoms, including visual field loss, reduced visual acuity, and diplopia. The management of bilateral occipital metastases involves consideration of symptomatology, disease burden, and goals of care. Visual deficits frequently improve following treatment but may also develop in a minority of patients.