Radiation-induced Cavernous Malformation Research Articles

Recurrent Radiation-Induced Cavernous Malformation After Gamma Knife Stereotactic Radiosurgery for Brain Metastasis

Cavernous malformations are a rare complication of radiation therapy reported most commonly as a late complication after cranial irradiation for pediatric malignancies. However, cavernous malformations after stereotactic radiosurgery in adult patients are not well characterized. We present a case of a 67-year-old female with metastatic breast cancer who received Gamma Knife stereotactic radiosurgery for brain metastases and developed a cavernous malformation at the site of a treated metastasis 30 months after treatment. She underwent resection and did well until 55 months later, when she developed symptomatic recurrence of cavernous malformation without evidence of tumor recurrence, requiring repeat resection. This represents the first reported case of radiation-induced cavernous malformation treated with stereotactic radiosurgery for brain metastases, who later developed a recurrence of the cavernous malformation. As patients with brain metastases are living longer and are increasingly treated with stereotactic radiosurgery, awareness of cavernous malformation as a potential complication and the risk of recurrence is critical to ensure appropriate diagnosis and management.

Radiation-induced cavernous malformation after stereotactic radiosurgery for cavernous sinus meningioma: a case report

BackgroundRadiation-induced cavernous malformation (RICM) is a rare sequela of stereotactic radiosurgery (SRS) treatment of intracranial tumors. To date, no study reported on RICM after SRS for meningiomas originating from the skull base. The relationship between locus of initial meningioma and RICM has not been studied.Case presentationA 57-year-old woman presented with persistent headaches and blepharoptosis at initial episode. MRI disclosed a right parasellar lesion, diagnosed as a cavernous sinus meningioma (CSM). After receiving a single-fractionated SRS, headache relieved, but blepharoptosis did not significantly improve. Three years and three months later, she returned with headaches and dizziness. MRI showed an enlarged CSM. Moreover, a new mass-like lesion, suspected hemangioma, appeared in the nearby right temporal lobe. After surgical removal of the new lesion and the CSM, the patient’s neurological symptoms significantly improved. Pathology confirmed CSM and temporal RICM.ConclusionsWe report the first rare case of RICM occurring after SRS for CSM. The RICM may be in the same region as the initial tumor. Surgical intervention was preferred for symptomatic RICM and initial meningioma. We recommend long-term regular followup MRIs for patients with meningioma after SRS treatment.

Acute and chronic hemorrhage from radiation-induced cavernous malformation associated with late-delayed radiation necrosis in long surviving glioma patients: A case report.

Although radiation therapy is a standard treatment strategy for patients with glioma, its delayed complications are not clearly understood. Radiation-induced cavernous malformation (RICM) is one of the complications in the delayed phase following radiation therapy, which usually occurs in children. Herein we present three cases of RICM with radiation necrosis in long surviving adult glioma patients, 2 with oligoastrocytoma and one with anaplastic ependymoma. Two of three patients had received an obvious overdose of radiation by additional stereotactic radiation therapy. Repeated episodes of either acute or chronic hemorrhages from RICM worsened the neurological symptoms in all cases. The interval between the last irradiation and the occurrence of symptoms was 45-173 months. The presence of hypointense rim on FLAIR or T2* on magnetic resonance imaging, which resembles the appearance of sporadic cavernous malformations, could be helpful in differentiating RICM from tumor recurrence. Surgical resection was effective in alleviating the symptoms. Microscopically, RICM is a vascular lesion with vulnerable vessels, which are observed in the center of the radiation necrosis. Repeated hemorrhages from these vessels cause either gradual or sudden worsening of neurological symptoms. Therefore, radiation overdose, which results in radiation injury, should be avoided in low grade glioma patients, who could potentially survive for a long period.

A patient with drug-resistant epilepsy who showed seizure freedom after hemorrhage related to radiation-induced cavernous malformation

We present a case of seizure freedom after spontaneous hemorrhage of the epileptic focus. A 47-year-old male patient, who has had focal tonic seizures since age 13, suffered from drug-resistant epilepsy presenting as 3~5 episodes of seizures every day. As the MRI showed a cystic mass at right insular cortex, he underwent gamma-knife surgery 17 years ago but the seizure frequency was not reduced. After surgery, he had a small, slowly-growing hemorrhagic residue in the right insula, which was considered as radiation-induced cavernous malformation. The patient had been given over 14 anti-epileptic drugs (AEDs); however, the seizures were not stopped. Suddenly, he reported seizure freedom for over 4 months with the same AEDs treatment. His follow-up MRI showed acute bleeding of pre-existing cavernous malformation at right insular area, while the patient did not show any neurologic deficit. Craniotomy with removal of hemorrhage was done, and seizure freedom maintained even after levetiracetam and phenobarbital were tapered out. This demonstrates a rare case of self-destruction of epileptic focus due to hemorrhage. Figure :(A) At first visit, 17 years ago, T2 MRI showed 1.5cm-sized cystic mass lesion in right insular cortex. (B) After gamma-knife surgery, a small radiation-induced cavernous malformation was seen. (C) When patient reported seizure freedom for over 4 months, acute bleeding of pre-existing cavernous malformation at right frontal lobe was noted, with 3cm-sized hematoma formation at right striatocapsule region. (D) After craniotomy, MRI showed residual edema in right hemisphere.

Long-term follow-up of intensive chemotherapy followed by reduced-dose and reduced-field irradiation for intracranial germ cell tumor.

OBJECTIVE The authors analyzed the efficacy of intensive chemotherapy followed by reduced-dose and reduced-field irradiation for intracranial germ cell tumors (GCTs) and evaluated the long-term late effects caused by chemoradiotherapy (CRT). METHODS The authors performed a retrospective study. The subjects were 24 patients who received CRT between April 1994 and April 2015. After surgery, intensive chemotherapy followed by reduced-dose and reduced-field irradiation was administered. For those with pure germinoma, who comprised the “good prognosis” group, five courses of conventional-dose chemotherapy (CDC) were administered, and radiotherapy (24 Gy) was applied to the whole ventricle. For all others, defined as the “intermediate and poor prognosis” group, two or three courses of CDC and high-dose chemotherapy were administered with peripheral blood stem cell transplantation and radiotherapy (24–30 Gy) applied to the whole ventricle or a larger field with or without local boost irradiation (20 Gy), which was applied as needed. RESULTS The median period of follow-up was 112.5 months (range 28–261 months), and the 5-/10-year overall and progression-free survival rates were 100%/83.5% and 91.3%/86.5%, respectively. The 5-/10-year overall survival rates determined based on the histological subtypes were 100%/100% for pure germinoma and 93.8%/78.7% for others, respectively. The late toxicities were as follows: endocrine disorder (33% in pure germinoma, 56% in others), involuntary movements (17% in pure germinoma, 39% in others), ear and labyrinth disorders (17% in pure germinoma, 33% in others), and psychiatric disorders (0% in pure germinoma, 33% in others). Nineteen of 24 patients underwent MRI (T2*- or susceptibility-weighted imaging) after radiotherapy, and 16 (84%) of those 19 patients had microbleeds detected, while 2 (10.5%) had radiation-induced cavernous vascular malformations detected. CONCLUSIONS Intensive chemotherapy followed by reduced-dose and reduced-field irradiation for intracranial GCTs had the same outcome as that reported in the literature, but late adverse effects after treatment were observed. Almost all of the complications were relatively mild but had the potential to lead to psychiatric disorders and intracranial hemorrhaging. ABBREVIATIONS AFP = alpha-fetoprotein; CDC = conventional-dose chemotherapy; CMB = cerebral microbleed; CRT = chemoradiotherapy; CSI = craniospinal irradiation; EP = etoposide and cisplatin; GCT = germ cell tumor; HCG = human chorionic gonadotropin; HDC = high-dose chemotherapy; ICE = ifosfamide, cisplatin, and etoposide; NGGCT = nongerminomatous GCT; OS = overall survival; PBSCT = peripheral blood stem cell transplantation; PFS = progression-free survival; RICM = radiation-induced cavernous malformation; STGC = syncytiotrophoblastic giant cell; SWI = susceptibility-weighted imaging.

NIMG-76HIGH INCIDENCE OF ABERRANT PARAMAGNETIC SIGNALS ON MRI OF ADULT PATIENTS SURVIVING TWO OR MORE YEARS AFTER BRAIN IRRADIATION THAT SIGNIFIES RADIATION-INDUCED LATE EFFECTS

BACKGROUND: Late complications of cerebral radiation therapy involve vascular injury that may lead to development of cavernous malformation (CM), telangiectasias and damage to vascular walls. Radiation-induced CM is a recognized late complication in children but its incidence in adult patients is unknown. Typically, blood products, iron deposition and calcifications which accompany vascular injury/malformation create paramagnetic/diamagnetic effects on MRI. OBJECTIVE: To retrospectively investigate frequency of MRI paramagnetic lesions in adult patients surviving >2 years after cranial irradiation. METHODS: We reviewed MRI studies of 60 patients followed for > 2 years after radiotherapy. Studies that did not have either susceptibility weighted images or gradient echo sequence or blood oxygenation level dependant imaging sequences were excluded from the study. Lesions inside the tumor volume were not considered. RESULTS: 34 studies fulfilled the inclusion criteria. The underlying pathology requiring radiotherapy included glial tumors (20), lymphoma (4), and others. The median age at time of radiotherapy was 44 years (range 20 -71). Aberrant paramagnetic/diamagnetic lesions were found in 22 (65%) patients. The size of the lesions ranged between 1-9 mm. The number of lesions varied: 10 patients had 1-5 lesions, 5 had 6-10 and 7 had >10 lesions. In one case the finding was associated with venous anomaly. Most lesions were within the radiation field and none of the patients had related symptomatology. The median interval between radiation and the study MRI was 6 years (range 2-29). No statistical difference was found in patients' age or in the interval from radiation between those who developed signal abnormality and those who did not. CONCLUSIONS: MRI paramagnetic/diamagnetic signal aberrations, consistent with CM and/or calcifications, are common findings which signify late effects of radiotherapy in adult brain tumor patients surviving >2 years after treatment. These lesions are benign and do not require intervention.

Radiation-induced cavernous malformation at the site of arteriovenous malformation following gamma knife radiosurgery: Case report

The common complications occurring after radiosurgery nclude persistent edema, radiation necrosis and cyst formaion. Unusual complications such as radiation-related tumors and adiation-induced CMs have also recently been reported. Gamma nife was commonly used to treat AVM, but a de novo CM after hat has not been reported. Generally, the complete obliteration of erebral AVM occurs from 4 months to 5 years after radiosurgery 1]. We present the first documented case of radiation-induced CM ollowing gamma knife surgery for an AVM.

Intracerebral Cavernous Malformation Induced by Radiosurgery-Case Report-

A 37-year-old man was treated for lung cancer by chemo-radiation therapy. Subsequently, magnetic resonance (MR) imaging identified a ring-enhanced lesion in the left temporal lobe. Gamma knife radiosurgery was performed under a diagnosis of brain metastasis. Nevertheless, MR imaging showed regrowth of the tumor 1 year later, so radiosurgery was repeated on the same lesion. Two years after the first radiosurgery, MR imaging revealed an irregularly enhanced lesion with increasing perifocal edema in the left temporal lobe. Emergency surgery was performed under a diagnosis of impending uncal herniation. The histological diagnosis was cavernous malformation. This case demonstrates that gamma knife radiosurgery can cause radiation-induced cavernous malformation.