Skip to main content

Advertisement

SpringerLink
Log in

Operative intervention for delayed symptomatic radionecrotic masses developing following stereotactic radiosurgery for cerebral arteriovenous malformations—case analysis and literature review

  • Case Report
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Case report

We report two cases of operative intervention that was beneficial in the treatment of delayed symptomatic radionecrotic masses that had developed following stereotactic radiosurgery (SRS) using the gamma knife (GK) for the treatment of cerebral arteriovenous malformations (AVM).

Discussion

Case 1 involved a small craniotomy for decompression of a large cerebral multiloculated cyst, which had become symptomatic 84 months following gamma knife treatment for a left frontal lobe AVM. Case 2 involved surgical excision of an occipital radionecrotic mass 72 months following GK treatment for an occipital AVM. This patient had suffered from longstanding symptomatic cerebral oedema, which on occasions had become life threatening. Case 2 is also the first report of a radionecrotic mass occurring post-SRS for an AVM, which conversely appeared to demonstrate increased uptake on single photon emission computed tomography (SPECT) scan. The first literature review of such delayed symptomatic radionecrotic lesions is presented. There appears to be a late onset of symptoms (average 55 months, range 12–111 months) associated with such radionecrosis. Drainage of such cysts or excision of the mass lesion appears to be consistently beneficial to the patients and appears to be uncomplicated.

Conclusion

We recommend early surgical intervention for such delayed symptomatic radionecrotic masses that do not resolve following non-operative management. We also recommend caution in interpretation of SPECT scan results when attempting to differentiate radionecrosis from neoplasia.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12

References

  1. Berman EL, Eade TN, Brown D, Weaver M, Glass J, Zorman G, Feigenberg SJ (2007) Radiation-induced tumor after stereotactic radiosurgery for an arteriovenous malformation: case report. Neurosurgery 61:E1099, discussion E1099

    Article  PubMed  Google Scholar 

  2. Bitzer M, Opitz H, Popp J, Morgalla M, Gruber A, Heiss E, Voigt K (1998) Angiogenesis and brain oedema in intracranial meningiomas: influence of vascular endothelial growth factor. Acta Neurochir (Wien) 140:333–340

    Article  CAS  Google Scholar 

  3. Chang TC, Shirato H, Aoyama H, Ushikoshi S, Kato N, Kuroda S, Ishikawa T, Houkin K, Iwasaki Y, Miyasaka K (2004) Stereotactic irradiation for intracranial arteriovenous malformation using stereotactic radiosurgery or hypofractionated stereotactic radiotherapy. Int J Radiat Oncol Biol Phys 60:861–870

    PubMed  Google Scholar 

  4. Devaux B, Nataf F, Beuvon F, Peragut JC, Boissonnet H, Page P, Turak B, Schlienger M (2001) Surgical removal of radio-induced lesions after radiosurgery of cerebral arteriovenous malformations. Neurochirurgie 47:318–323

    PubMed  CAS  Google Scholar 

  5. Flickinger JC, Kondziolka D, Lunsford LD, Kassam A, Phuong LK, Liscak R, Pollock B (2000) Development of a model to predict permanent symptomatic postradiosurgery injury for arteriovenous malformation patients. Arteriovenous malformation radiosurgery study group. Int J Radiat Oncol Biol Phys 46:1143–1148

    PubMed  CAS  Google Scholar 

  6. Flickinger JC, Kondziolka D, Lunsford LD, Pollock BE, Yamamoto M, Gorman DA, Schomberg PJ, Sneed P, Larson D, Smith V, McDermott MW, Miyawaki L, Chilton J, Morantz RA, Young B, Jokura H, Liscak R (1999) A multi-institutional analysis of complication outcomes after arteriovenous malformation radiosurgery. Int J Radiat Oncol Biol Phys 44:67–74

    Article  PubMed  CAS  Google Scholar 

  7. Flickinger JC, Kondziolka D, Pollock BE, Maitz AH, Lunsford LD (1997) Complications from arteriovenous malformation radiosurgery: multivariate analysis and risk modeling. Int J Radiat Oncol Biol Phys 38:485–490

    PubMed  CAS  Google Scholar 

  8. Flickinger JC, Lunsford LD, Kondziolka D, Maitz AH, Epstein AH, Simons SR, Wu A (1992) Radiosurgery and brain tolerance: an analysis of neurodiagnostic imaging changes after gamma knife radiosurgery for arteriovenous malformations. Int J Radiat Oncol Biol Phys 23:19–26

    PubMed  CAS  Google Scholar 

  9. Forster DM (1995) Complication management. Presented at the 2nd Congress of the International Stereotactic Radiosurgery Society Boston:14–17

  10. Friedman WA, Bova FJ, Bollampally S, Bradshaw P (2003) Analysis of factors predictive of success or complications in arteriovenous malformation radiosurgery. Neurosurgery 52:296–307, discussion 307-298

    Article  PubMed  Google Scholar 

  11. Ganz JC, Reda WA, Abdelkarim K, Hafez A (2005) A simple method for predicting imaging-based complications following gamma knife surgery for cerebral arteriovenous malformations. J Neurosurg 102:4–7

    Article  PubMed  Google Scholar 

  12. Goldman CK, Bharara S, Palmer CA, Vitek J, Tsai JC, Weiss HL, Gillespie GY (1997) Brain edema in meningiomas is associated with increased vascular endothelial growth factor expression. Neurosurgery 40:1269–1277

    Article  PubMed  CAS  Google Scholar 

  13. Hara M, Nakamura M, Shiokawa Y, Sawa H, Sato E, Koyasu H, Saito I (1998) Delayed cyst formation after radiosurgery for cerebral arteriovenous malformation: two case reports. Minim Invasive Neurosurg 41:40–45

    Article  PubMed  CAS  Google Scholar 

  14. Izawa M, Hayashi M, Chernov M, Nakaya K, Ochiai T, Murata N, Takasu Y, Kubo O, Hori T, Takakura K (2005) Long-term complications after gamma knife surgery for arteriovenous malformations. J Neurosurg 102:34–37

    Article  PubMed  Google Scholar 

  15. Kaido T, Hoshida T, Uranishi R, Akita N, Kotani A, Nishi N, Sakaki T (2001) Radiosurgery-induced brain tumor. Case report. J Neurosurg 95:710–713

    Article  PubMed  CAS  Google Scholar 

  16. Karlsson B, Lax I, Soderman M (1997) Factors influencing the risk for complications following gamma knife radiosurgery of cerebral arteriovenous malformations. Radiother Oncol 43:275–280

    Article  PubMed  CAS  Google Scholar 

  17. Kemeny AA, Radatz MW, Rowe JG, Walton L, Hampshire A (2004) Gamma knife radiosurgery for cerebral arteriovenous malformations. Acta Neurochir Suppl 91:55–63

    PubMed  CAS  Google Scholar 

  18. Kihlstrom L, Guo WY, Karlsson B, Lindquist C, Lindqvist M (1997) Magnetic resonance imaging of obliterated arteriovenous malformations up to 23 years after radiosurgery. J Neurosurg 86:589–593

    Article  PubMed  CAS  Google Scholar 

  19. Kim MS, Lee SI, Sim JH (1999) A case of very large cyst formation with gamma knife radiosurgery for an arteriovenous malformation. Stereotact Funct Neurosurg 72(Suppl 1):168–174

    Article  PubMed  Google Scholar 

  20. Lax I, Karlsson B (1996) Prediction of complications in gamma knife radiosurgery of arteriovenous malformation. Acta Oncol 35:49–55

    Article  PubMed  CAS  Google Scholar 

  21. Leber KA, Eder HG, Kovac H, Anegg U, Pendl G (1998) Treatment of cerebral radionecrosis by hyperbaric oxygen therapy. Stereotact Funct Neurosurg 70(Suppl 1):229–236

    Article  PubMed  Google Scholar 

  22. Leksell DG (1987) Stereotactic radiosurgery present status and future trends. Neurol Res 9:60–68

    PubMed  CAS  Google Scholar 

  23. Liscak R, Vladyka V, Simonova G, Urgosik D, Novotny J Jr, Janouskova L, Vymazal J (2007) Arteriovenous malformations after Leksell gamma knife radiosurgery: rate of obliteration and complications. Neurosurgery 60:1005–1014, discussion 1015-1006

    PubMed  Google Scholar 

  24. Lorberboym M, Mandell LR, Mosesson RE, Germano I, Lou W, DaCosta M, Linzer DG, Machac J (1997) The role of thallium-201 uptake and retention in intracranial tumors after radiotherapy. J Nucl Med 38:223–226

    PubMed  CAS  Google Scholar 

  25. Lorberboym M, Sacher M (1997) False-positive uptake of TI-201 by an intracranial inflammatory pseudotumor. Clin Nucl Med 22:756–758

    Article  PubMed  CAS  Google Scholar 

  26. Lunsford LD, Flickinger J, Coffey RJ (1990) Stereotactic gamma knife radiosurgery. Initial North American experience in 207 patients. Arch Neurol 47:169–175

    PubMed  CAS  Google Scholar 

  27. Lunsford LD, Kondziolka D, Flickinger JC, Bissonette DJ, Jungreis CA, Maitz AH, Horton JA, Coffey RJ (1991) Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 75:512–524

    Article  PubMed  CAS  Google Scholar 

  28. Lunsford LD, Niranjan A, Kondziolka D, Sirin S, Flickinger JC (2008) Arteriovenous malformation radiosurgery: a twenty year perspective. Clinical Neurosurgery 55:109–119

    Google Scholar 

  29. Matheja P, Rickert C, Weckesser M, Hoss N, Schober O (2000) Scintigraphic pitfall: delayed radionecrosis. Case illustration. J Neurosurg 92:732

    Article  PubMed  CAS  Google Scholar 

  30. Miyawaki L, Dowd C, Wara W, Goldsmith B, Albright N, Gutin P, Halbach V, Hieshima G, Higashida R, Lulu B, Pitts L, Schell M, Smith V, Weaver K, Wilson C, Larson D (1999) Five year results of LINAC radiosurgery for arteriovenous malformations: outcome for large AVMS. Int J Radiat Oncol Biol Phys 44:1089–1106

    PubMed  CAS  Google Scholar 

  31. Pan HC, Sheehan J, Stroila M, Steiner M, Steiner L (2005) Late cyst formation following gamma knife surgery of arteriovenous malformations. J Neurosurg 102(Suppl):124–127

    Article  PubMed  Google Scholar 

  32. Plowman PN (1999) Stereotactic radiosurgery. VIII. The classification of postradiation reactions. Br J Neurosurg 13:256–264

    Article  PubMed  CAS  Google Scholar 

  33. Pollock BE (1999) Stereotactic radiosurgery for arteriovenous malformations. Neurosurg Clin N Am 10:281–290

    PubMed  CAS  Google Scholar 

  34. Pollock BE, Brown RD Jr (2001) Management of cysts arising after radiosurgery to treat intracranial arteriovenous malformations. Neurosurgery 49:259–264, discussion 264-255

    Article  PubMed  CAS  Google Scholar 

  35. Pollock BE, Gorman DA, Coffey RJ (2003) Patient outcomes after arteriovenous malformation radiosurgical management: results based on a 5- to 14-year follow-up study. Neurosurgery 52:1291–1296, discussion 1296-1297

    Article  PubMed  Google Scholar 

  36. Radanowicz-Harttmann V, Bachli H, Gratzl O (1998) Late complication of radiosurgery of AVMs with the gamma knife: a case report. Acta Neurochir (Wien) 140:194–195

    Article  CAS  Google Scholar 

  37. Rothbart D, Awad IA, Lee J, Kim J, Harbaugh R, Criscuolo GR (1996) Expression of angiogenic factors and structural proteins in central nervous system vascular malformations. Neurosurgery 38:915–924, discussion 924–915

    Article  PubMed  CAS  Google Scholar 

  38. Rowe J, Grainger A, Walton L, Silcocks P, Radatz M, Kemeny A (2007) Risk of malignancy after gamma knife stereotactic radiosurgery. Neurosurgery 60:60–65, discussion 65–66

    PubMed  Google Scholar 

  39. Sanno N, Hayashi S, Shimura T, Maeda S, Teramoto A (2004) Intracranial osteosarcoma after radiosurgery—case report. Neurol Med Chir (Tokyo) 44:29–32

    Article  Google Scholar 

  40. Schaller C, Liefner M, Ansari S, Al Moutaery K (2005) Operation for delayed symptomatic brain oedema after treatment of an arteriovenous malformation by embolization and radiosurgery. Acta Neurochir (Wien) 147:1103–1108, discussion 1108

    Article  CAS  Google Scholar 

  41. Shamisa A, Bance M, Nag S, Tator C, Wong S, Noren G, Guha A (2001) Glioblastoma multiforme occurring in a patient treated with gamma knife surgery. Case report and review of the literature. J Neurosurg 94:816–821

    Article  PubMed  CAS  Google Scholar 

  42. Statham P, Macpherson P, Johnston R, Forster DM, Adams JH, Todd NV (1990) Cerebral radiation necrosis complicating stereotactic radiosurgery for arteriovenous malformation. J Neurol Neurosurg Psych 53:476–479

    Article  CAS  Google Scholar 

  43. Steinberg GK, Fabrikant JI, Marks MP, Levy RP, Frankel KA, Phillips MH, Shuer LM, Silverberg GD (1990) Stereotactic heavy-charged-particle Bragg-peak radiation for intracranial arteriovenous malformations. N Engl J Med 323:96–101

    Article  PubMed  CAS  Google Scholar 

  44. Stephen M. Russell PDLR (2005) Arteriovenous malformations. Neurosurgery: principles and practice. Anne J Moore, David W Newell:349–365

  45. Strugar J, Rothbart D, Harrington W, Criscuolo GR (1994) Vascular permeability factor in brain metastases: correlation with vasogenic brain edema and tumor angiogenesis. J Neurosurg 81:560–566

    Article  PubMed  CAS  Google Scholar 

  46. Sutcliffe JC, Forster DM, Walton L, Dias PS, Kemeny AA (1992) Untoward clinical effects after stereotactic radiosurgery for intracranial arteriovenous malformations. Br J Neurosurg 6:177–185

    Article  PubMed  CAS  Google Scholar 

  47. Tashima T, Morioka T, Nishio S, Hachisuga S, Fukui M, Sasaki M (1998) Delayed cerebral radionecrosis with a high uptake of 11C-methionine on positron emission tomography and 201Tl-chloride on single-photon emission computed tomography. Neuroradiology 40:435–438

    Article  PubMed  CAS  Google Scholar 

  48. Voges J, Treuer H, Sturm V, Buchner C, Lehrke R, Kocher M, Staar S, Kuchta J, Muller RP (1996) Risk analysis of linear accelerator radiosurgery. Int J Radiat Oncol Biol Phys 36:1055–1063

    PubMed  CAS  Google Scholar 

  49. Wolak ML, Murphy EC, Powell SZ (2007) Tumefactive cyst with a vascular blush as a late complication after combined embolization and stereotactic radiosurgery treatments for a cerebral arteriovenous malformation. Acta Neurochir (Wien) 149:705–712, discussion 712

    Article  CAS  Google Scholar 

  50. Yamamoto M, Jimbo M, Hara M, Saito I, Mori K (1996) Gamma knife radiosurgery for arteriovenous malformations: long-term follow-up results focusing on complications occurring more than 5 years after irradiation. Neurosurgery 38:906–914

    Article  PubMed  CAS  Google Scholar 

  51. Yamamoto M, Jimbo M, Lindquist C (1992) Radiation-induced edema after radiosurgery for pontine arteriovenous malformation. A case report and detection by magnetic resonance imaging. Surg Neurol 37:15–21

    Article  PubMed  CAS  Google Scholar 

  52. Yoshioka H, Hama S, Taniguchi E, Sugiyama K, Arita K, Kurisu K (1999) Peritumoral brain edema associated with meningioma: influence of vascular endothelial growth factor expression and vascular blood supply. Cancer 85:936–944

    Article  PubMed  CAS  Google Scholar 

  53. Yu JS, Yong WH, Wilson D, Black KL (2000) Glioblastoma induction after radiosurgery for meningioma. Lancet 356:1576–1577

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurosurgery, University Hospital of Wales Cardiff, Heath Park, Cardiff, CF14 4XW, UK

    Mansoor Foroughi & Richard Hatfield

  2. Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, UK

    Andras A. Kemeny

  3. Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland

    Martin Lehecka, Juliana Wons & Lisa Kajdi

  4. Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK

    Sidney Marks

Authors
  1. Mansoor Foroughi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Andras A. Kemeny
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Martin Lehecka
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Juliana Wons
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Lisa Kajdi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Richard Hatfield
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sidney Marks
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mansoor Foroughi.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Foroughi, M., Kemeny, A.A., Lehecka, M. et al. Operative intervention for delayed symptomatic radionecrotic masses developing following stereotactic radiosurgery for cerebral arteriovenous malformations—case analysis and literature review. Acta Neurochir 152, 803–815 (2010). https://doi.org/10.1007/s00701-009-0581-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-009-0581-1

Keywords

Search

Navigation