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Mizowaki T, Fujita A, Tanaka H, Takaishi Y, Kondoh T. Ruptured giant serpentine aneurysm of anterior cerebral artery long after Gamma Knife radiosurgery for cerebral arteriovenous malformation. Neurochirurgie 2023; 69:101447. [PMID: 37146509 DOI: 10.1016/j.neuchi.2023.101447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/18/2023] [Indexed: 05/07/2023]
Affiliation(s)
- Takashi Mizowaki
- Department of Neurosurgery, Shinsuma General Hospital, 3-1-14 Kinugake-cho, Suma-ku, 654-0048 Hyogo, Kobe, Japan.
| | - Atsushi Fujita
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-2 Chuo-ku, Kusunoki-cho, 650-0017 Hyogo, Kobe, Japan
| | - Hirotomo Tanaka
- Department of Neurosurgery, Shinsuma General Hospital, 3-1-14 Kinugake-cho, Suma-ku, 654-0048 Hyogo, Kobe, Japan
| | - Yoshiyuki Takaishi
- Department of Neurosurgery, Shinsuma General Hospital, 3-1-14 Kinugake-cho, Suma-ku, 654-0048 Hyogo, Kobe, Japan
| | - Takeshi Kondoh
- Department of Neurosurgery, Shinsuma General Hospital, 3-1-14 Kinugake-cho, Suma-ku, 654-0048 Hyogo, Kobe, Japan
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Yang WH, Yang YH, Chen PC, Wang TC, Chen KJ, Cheng CY, Lai CH. Intracranial aneurysms formation after radiotherapy for head and neck cancer: a 10-year nationwide follow-up study. BMC Cancer 2019; 19:537. [PMID: 31164088 PMCID: PMC6549276 DOI: 10.1186/s12885-019-5766-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 05/29/2019] [Indexed: 11/29/2022] Open
Abstract
Background Intracranial aneurysms after radiotherapy (RT) have previously been reported. However, the majority of studies were case reports. Therefore, we performed a nationwide study to explore the risk of radiation-induced intracranial aneurysms. Methods This study included patients diagnosed with head and neck cancer (ICD9: 140–149, 161). Intracranial aneurysms formation was identified using the following ICD9 codes: nonruptured cerebral aneurysm (ICD9:4373), aneurysm clipping (ICD9:3951). Patients who did not receive curative treatment and those with intracranial aneurysms before the diagnosis of head and neck cancer were excluded. Results In total, 70,691 patients were included in the final analysis; they were categorized into the following three groups: nasopharyngeal carcinoma (NPC) with RT, non-NPC with RT, and non-NPC without RT. Patients in the NPC with RT group had the highest risk of developing intracranial aneurysms (hazard ratio (HR) 2.57; P < 0.001). In addition, hypertension was also a risk factor of developing intracranial aneurysms (HR 2.14; P < 0.01). The mean time interval from cancer diagnosis to intracranial aneurysm formation in the NPC with RT group was 4.3 ± 3.1 years. Conclusions Compared with the non-NPC with RT and the non-NPC without RT groups, patients with NPC who received RT had a higher risk of developing intracranial aneurysms.
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Affiliation(s)
- Wei-Hsun Yang
- Division of Neurosurgery, Department of Surgery, Chang Gung Memorial Hospital, Chia-Yi, Taiwan
| | - Yao-Hsu Yang
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Chia-Yi, Taiwan.,Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi, Taiwan.,School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pau-Chung Chen
- Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan.,Department of Environmental and Occupational Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ting-Chung Wang
- Division of Neurosurgery, Department of Surgery, Chang Gung Memorial Hospital, Chia-Yi, Taiwan
| | - Ko-Jung Chen
- Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chun-Yu Cheng
- Division of Neurosurgery, Department of Surgery, Chang Gung Memorial Hospital, Chia-Yi, Taiwan
| | - Chia-Hsuan Lai
- Department of Radiation Oncology, Chang Gung Memorial Hospital, No 6, West Section, Chia-Pu Road, Putz City, Chia-Yi, Taiwan, 613.
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Dho YS, Kim DG, Chung HT. Ruptured de novo Aneurysm following Gamma Knife Surgery for Arteriovenous Malformation: Case Report. Stereotact Funct Neurosurg 2017; 95:379-384. [PMID: 29190619 DOI: 10.1159/000481666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/19/2017] [Indexed: 11/19/2022]
Abstract
Stereotactic radiosurgery is a well-known treatment tool for arteriovenous malformations (AVMs). The method has high validity and minimal invasiveness, but late-onset problems involving tumor formation and vasculopathy induced by radiation have been reported. We present a rare case of a radiation-induced ruptured de novo aneurysm following Gamma Knife surgery (GKS) for an AVM. A 17-year-old, right-handed male underwent GKS for AVM at the left parietal lobe. After 3 years, a follow-up angiogram showed a residual AVM at the angular gyrus. Then, a 2nd GKS was performed for the residual lesion. Six years after the 1st GKS, the AVM disappeared on the angiogram. Seven years later, he suffered a sudden onset of headache. A left carotid angiogram revealed a ruptured aneurysm at the M2-M3 junction of the middle cerebral artery parietal branch. Coil embolization was performed, and the aneurysm was occluded. The patient was discharged without any neurologic deficits.
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Affiliation(s)
- Yun-Sik Dho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Delayed Development of Aneurysms Following Gamma Knife Surgery for Trigeminal Neuralgia: Report of 2 Cases. World Neurosurg 2016; 99:813.e13-813.e19. [PMID: 27890752 DOI: 10.1016/j.wneu.2016.11.069] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 11/13/2016] [Accepted: 11/15/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Delayed development of intracranial aneurysms is an extremely rare complication of gamma knife surgery (GKS), with only 6 cases been reported to date. There are no reported cases after GKS performed to treat trigeminal neuralgia (TN). Of the 6 aforementioned cases, none referred to the natural history or pathophysiology of GKS-related intracranial aneurysm formation. CASE DESCRIPTION We treated 2 patients with subarachnoid hemorrhage (SAH) resulting from rupture of an intracranial aneurysm that developed long after GKS. Case 1 involved a 77-year-old man who had undergone GKS to treat recurrent TN after microvascular decompression surgery. At 13 years after the GSK, he developed SAH from a ruptured left anterior inferior cerebellar artery in close vicinity to the left trigeminal nerve. He died from a premature rupture before intervention could be instituted. Case 2 involved a 72-year-old woman who developed SAH at 9 years after undergoing GKS for TN. A ruptured left superior cerebellar artery aneurysm was treated successfully with endovascular occlusion of the parent artery. She recovered well after the surgery, and was discharged to the rehabilitation hospital with a modified Rankin Scale score of 2. CONCLUSION Long-term observations are necessary after GKS performed for TN owing to the possibility of formation of intracranial aneurysms near the irradiated region.
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Smyth LML, Senthi S, Crosbie JC, Rogers PAW. The normal tissue effects of microbeam radiotherapy: What do we know, and what do we need to know to plan a human clinical trial? Int J Radiat Biol 2016; 92:302-11. [DOI: 10.3109/09553002.2016.1154217] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Lloyd M. L. Smyth
- University of Melbourne, Department of Obstetrics and Gynaecology, Royal Women's Hospital, Parkville, Victoria, Australia
- Epworth Radiation Oncology, Epworth HealthCare, Melbourne, Victoria, Australia
| | - Sashendra Senthi
- William Buckland Radiotherapy Centre, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jeffrey C. Crosbie
- William Buckland Radiotherapy Centre, Alfred Hospital, Melbourne, Victoria, Australia
- School of Applied Sciences, RMIT University, Melbourne, Victoria, Australia
| | - Peter A. W. Rogers
- University of Melbourne, Department of Obstetrics and Gynaecology, Royal Women's Hospital, Parkville, Victoria, Australia
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Akai T, Torigoe K, Fukushima M, Iizuka H, Hayashi Y. De Novo Aneurysm Formation Following Gamma Knife Surgery for Arteriovenous Malformation: A Case Report. J Neurol Surg Rep 2015; 76:e105-8. [PMID: 26251783 PMCID: PMC4520975 DOI: 10.1055/s-0035-1549223] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 01/13/2015] [Indexed: 10/26/2022] Open
Abstract
Background Stereotactic radiosurgery plays a critical role in the treatment of central nervous system neoplasm and cerebrovascular malformations. This procedure is purportedly less invasive, but problems occurring later including tumor formation, necrosis, and vasculopathy-related diseases have been reported. Clinical Presentation We report on a 65-year-old man who had experienced a de novo aneurysm in an irradiated field and an acute onset of right hemiparesis and aphasia. He had undergone gamma knife radiosurgery to treat an arteriovenous malformation 15 and 12 years prior, with 18 and 22 Gy marginal doses. At current admission, radiologic studies showed a de novo aneurysm in the irradiated field without recurrence of malformation. The aneurysm was resected. Histologic findings showed a disruption of the internal elastic lamina accompanied by fibrous degeneration. Conclusion Stereotactic radiosurgery is a promising treatment tool, but long-term risks have not been fully researched. The treatment procedure for benign lesions should be chosen prudently.
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Affiliation(s)
- Takuya Akai
- Department of Neurosurgery, Kanazawa Medical University, Kanazawa, Japan
| | - Keiichiro Torigoe
- Department of Neurosurgery, Kanazawa Medical University, Kanazawa, Japan
| | - Manna Fukushima
- Pathology and Laboratory Medicine, Kanazawa Medical University, Kanazawa, Japan
| | - Hideaki Iizuka
- Department of Neurosurgery, Kanazawa Medical University, Kanazawa, Japan
| | - Yasuhiko Hayashi
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan
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Kim DH, Kang DH, Park J, Hwang JH, Park SH, Son WS. Delayed Perilesional Ischemic Stroke after Gamma-knife Radiosurgery for Unruptured Deep Arteriovenous Malformation: Two Case Reports of Radiation-induced Small Artery Injury as Possible Cause. J Cerebrovasc Endovasc Neurosurg 2015; 17:36-42. [PMID: 25874184 PMCID: PMC4394118 DOI: 10.7461/jcen.2015.17.1.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 12/22/2014] [Accepted: 02/23/2015] [Indexed: 11/23/2022] Open
Abstract
Radiation-induced vasculopathy is a rare occurrence, however, it is one of the most serious complications that can occur after gamma-knife radiosurgery (GKRS). The authors present two cases of incidentally found deep cerebral arteriovenous malformation (AVM), which were treated by GKRS, where subsequently there occurred delayed-onset cerebral infarction (11 and 17 months after GKRS) at an area adjacent to the AVM. In both cases, perforators of the M1 segment of the middle cerebral artery were included in the radiation field and delayed injury to these is suggested to be the mechanism of the ischemic event.
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Affiliation(s)
- Dong-Han Kim
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea
| | - Dong-Hun Kang
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea. ; Department of Radiology, Kyungpook National University Hospital, Daegu, Korea
| | - Jaechan Park
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea
| | - Jeong-Hyun Hwang
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea
| | - Seong-Hyun Park
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea
| | - Won-Soo Son
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea
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Abstract
Stereotactic radiosurgery for intracranial arteriovenous malformations (AVMs) has been performed since the 1970s. When an AVM is treated with radiosurgery, radiation injury to the vascular endothelium induces the proliferation of smooth muscle cells and the elaboration of extracellular collagen, which leads to progressive stenosis and obliteration of the AVM nidus. Obliteration after AVM radiosurgery ranges from 60% to 80%, and relates to the size of the AVM and the prescribed radiation dose. The major drawback of radiosurgical AVM treatment is the risk of bleeding during the latent period (typically 2 years) between treatment and AVM thrombosis.
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Affiliation(s)
- William A Friedman
- Department of Neurological Surgery, University of Florida, PO Box 100265, MBI, Gainesville, FL 32610, USA.
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Gross BA, Chiocca EA. Neoplasm development after stereotactic radiosurgery for arteriovenous malformations. World Neurosurg 2013; 82:304-6. [PMID: 23416772 DOI: 10.1016/j.wneu.2013.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Accepted: 02/08/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Bradley A Gross
- Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA; Institute for the Neurosciences at the Brigham and Women's/Faulkner Hospital, Boston, Massachusetts, USA
| | - E Antonio Chiocca
- Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA; Institute for the Neurosciences at the Brigham and Women's/Faulkner Hospital, Boston, Massachusetts, USA; Center for Neuro-oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.
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Gross BA, Ropper AE, Du R. Vascular complications of stereotactic radiosurgery for arteriovenous malformations. Clin Neurol Neurosurg 2012; 115:713-7. [PMID: 22910397 DOI: 10.1016/j.clineuro.2012.08.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 05/16/2012] [Accepted: 08/05/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Although vasculopathy and de novo aneurysm formation are known complications of traditional radiation therapy, their occurrence following AVM SRS is rare and thus infrequently addressed in the literature. We sought to evaluate these phenomena through a review of our institutional experience. METHODS Our review afforded 32 patients treated with LINAC-based SRS over an eight year period. We noted obliteration rates, complication rates and long-term outcomes, with particular attention paid to follow-up angiographic studies. RESULTS After a mean follow-up of 4.3 years, the overall obliteration rate was 50%, increasing to 87% for AVMs less than 3cm. Eight patients had nine hemorrhages following SRS (25%). One occurred in the context of a de novo arterial pseudoaneurysm and another in the context of a new venous varix. Two patients with post-SRS hemorrhage had intranidal aneurysms that were not as apparent on initial angiography. Two patients that did not suffer from latency period hemorrhage developed dysplastic changes of feeding arteries, and one patient suffered from early venous thrombosis with resultant permanent hemiparesis from infarction. After a mean follow-up of 4.3 years, 8 patients were clinically improved (25%), 19 were the same (59%), and 5 were worse (16%), including 2 that died as a result of latency period hemorrhage. CONCLUSION While radiosurgery of AVMs is safe and successful in the vast majority of cases, vasculopathic complications including de novo aneurysm and varix development, early venous occlusion and stenotic vasculopathy, while infrequent, can occur. Closer long-term angiographic surveillance of these patients may thus be warranted.
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Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, United States
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Abstract
Stereotactic radiosurgery is the term coined by Lars Leksell to describe the application of a single, high dose of radiation to a stereotactically defined target volume. In the 1970s, reports began to appear documenting the successful obliteration of arteriovenous malformations (AVMs) with radiosurgery. When an AVM is treated with radiosurgery, a pathologic process appears to be induced that is similar to the response-to-injury model of atherosclerosis. Radiation injury to the vascular endothelium is believed to induce the proliferation of smooth-muscle cells and the elaboration of extracellular collagen, which leads to progressive stenosis and obliteration of the AVM nidus thereby eliminating the risk of hemorrhage. The advantages of radiosurgery - compared to microsurgical and endovascular treatments - are that it is noninvasive, has minimal risk of acute complications, and is performed as an outpatient procedure requiring no recovery time for the patient. The primary disadvantage of radiosurgery is that cure is not immediate. While thrombosis of the lesion is achieved in the majority of cases, it commonly does not occur until two or three years after treatment. During the interval between radiosurgical treatment and AVM thrombosis, the risk of hemorrhage remains. Another potential disadvantage of radiosurgery is possible long term adverse effects of radiation. Finally, radiosurgery has been shown to be less effective for lesions over 10 cc in volume. For these reasons, selection of the optimal treatment for an AVM is a complex decision requiring the input of experts in endovascular, open surgical, and radiosurgical treatment. In the pages below, we will review the world's literature on radiosurgery for AVMs. Topics reviewed will include the following: radiosurgical technique, radiosurgery results (gamma knife radiosurgery, particle beam radiosurgery, linear accelerator radiosurgery), hemorrhage after radiosurgery, radiation induced complications, repeat radiosurgery, and radiosurgery for other types of vascular malformation.
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Affiliation(s)
- William A Friedman
- Department of Neurological Surgery, University of Florida, Gainesville, FL 32610, USA.
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Lorenzoni J, David P, Levivier M. MR-based follow-up of the superior cerebellar artery after radiosurgery for trigeminal neuralgia. Clin Neurol Neurosurg 2011; 113:758-61. [DOI: 10.1016/j.clineuro.2011.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Revised: 07/04/2011] [Accepted: 08/05/2011] [Indexed: 10/17/2022]
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Friedman WA, Bova FJ. Radiosurgery for Arteriovenous Malformations. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10073-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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van der Sanden B, Bräuer-Krisch E, Siegbahn EA, Ricard C, Vial JC, Laissue J. Tolerance of Arteries to Microplanar X-Ray Beams. Int J Radiat Oncol Biol Phys 2010; 77:1545-52. [DOI: 10.1016/j.ijrobp.2010.02.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 02/15/2010] [Accepted: 02/17/2010] [Indexed: 11/30/2022]
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Park KY, Ahn JY, Lee JW, Chang JH, Huh SK. De novo intracranial aneurysm formation after Gamma Knife radiosurgery for vestibular schwannoma. J Neurosurg 2009; 110:540-2. [PMID: 19012483 DOI: 10.3171/2008.9.jns08860] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Vascular complications, including vessel occlusion and hemorrhage, can arise after radiosurgery; however, hemorrhage due to a ruptured de novo aneurysm after Gamma Knife radiosurgery (GKS) for tumor is extremely rare. To the authors' knowledge, only a single case of de novo aneurysm formation after GKS for vestibular schwannoma has been previously reported. In this study, they describe their experience with the treatment of a 74-year-old woman with subarachnoid hemorrhage limited to the cerebellopontine cistern, who had undergone GKS for vestibular schwannoma 5 years earlier. Cerebral angiography demonstrated a left distal anterior inferior cerebellar artery aneurysm; coil embolization was attempted and failed. However, self-resolution of the aneurysm was revealed on follow-up angiography.
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Affiliation(s)
- Keun Young Park
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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Lee JKL, Chelvarajah R, King A, David KM. Rare Presentations of Delayed Radiation Injury: A Lobar Hematoma and a Cystic Space-occupying Lesion Appearing More Than 15 Years after Cranial Radiotherapy: Report of Two Cases. Neurosurgery 2004; 54:1010-3; discussion 1013-4. [PMID: 15046671 DOI: 10.1227/01.neu.0000114868.82478.62] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2003] [Accepted: 10/07/2003] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE AND IMPORTANCE
Radiation vasculopathy and radionecrosis, constituting delayed radiation injury, are rare but recognized complications of radiation therapy occurring at a peak incidence of 3 years after treatment. Little information is available about these complications occurring more than 15 years after radiotherapy and presenting as other than solid intracranial masses.
CLINICAL PRESENTATION
We describe two patients who presented with space-occupying cerebral lesions. Patient 1 presented as an emergency with a sudden loss of consciousness. Computed tomography revealed a large left intracerebral hemorrhage; cerebral angiography disclosed nothing abnormal, and a primary spontaneous hemorrhage was presumed. Twenty-seven years earlier, this patient had received adjuvant whole-brain and spine radiotherapy and concomitant chemotherapy after excision of a vermis medulloblastoma. Patient 2 presented with a left frontal cystic lesion (presumed malignant glioma) as the cause of personality and behavioral changes for some months. She had previously received external beam radiation for a basal cell epithelioma, which had been excised from her left forehead 19 years earlier.
INTERVENTION
Both patients recovered well after undergoing craniotomies and removal of their lesions; they were discharged home with no neurological deficit.
CONCLUSION
Even after long intervals after radiotherapy, it is important to consider radiation vasculopathy and radionecrosis as differential diagnoses of more common conditions. Histological confirmation of a delayed radiation injury in the absence of any evidence of neoplasia or vascular abnormality has allowed appropriate prognosis and management to be formulated with confidence in each of these patients.
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Affiliation(s)
- Joshua K L Lee
- Department of Neurosurgery, Essex Centre for Neurological Sciences, Oldchurch Hospital, London, England, UK
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Stafford SL, Pollock BE, Foote RL, Link MJ, Gorman DA, Schomberg PJ, Leavitt JA. Meningioma Radiosurgery: Tumor Control, Outcomes, and Complications among 190 Consecutive Patients. Neurosurgery 2001. [DOI: 10.1227/00006123-200111000-00001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Stafford SL, Pollock BE, Foote RL, Link MJ, Gorman DA, Schomberg PJ, Leavitt JA. Meningioma radiosurgery: tumor control, outcomes, and complications among 190 consecutive patients. Neurosurgery 2001; 49:1029-37; discussion 1037-8. [PMID: 11846894 DOI: 10.1097/00006123-200111000-00001] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2001] [Accepted: 06/29/2001] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To determine local control (LC) and complication rates for patients with intracranial meningiomas who underwent radiosurgery. METHODS One hundred ninety consecutive patients with 206 meningiomas underwent radiosurgery between 1990 and 1998. One hundred forty-seven tumors (77%) involved the cranial base. The median age at the time of radiosurgery was 58 years (range, 20-90 yr). There were 126 female patients (66%). One hundred twelve patients (59%) had undergone one or more previous operations (median, 1; range, 1-5). Twenty-two patients (12%) had either atypical (n = 13) or malignant (n = 9) tumors. The median prescription isodose volume was 8.2 cm(3) (range, 0.5-50.5 cm(3)), and the median tumor margin dose was 16 Gy (range, 12-36 Gy). The median imaging and clinical follow-up periods were 40 and 47 months, respectively. RESULTS Overall survival rates for the entire cohort at 5 and 7 years were 82 and 82%, respectively; cause-specific survival rates at 5 and 7 years were 94 and 92%, respectively. The cause-specific survival rates at 5 years for patients with benign, atypical, and malignant tumors were 100, 76, and 0%, respectively (P < 0.0001). The 5-year LC rate was 89%, with 114 tumors (56%) decreasing in size. LC rates were correlated with tumor histological features (P < 0.0001); patients with benign tumors exhibited a 5-year LC rate of 93%, compared with 68 and 0% for patients with atypical or malignant meningiomas, respectively. No correlation was observed between radiation dose and LC rate. Twenty-four patients (13%) experienced treatment-related complications, including cranial nerve deficits (8%), symptomatic parenchymal changes (3%), internal carotid artery stenosis (1%), and symptomatic cyst formation (1%). Only six patients (3%) exhibited decreases in functional status that were directly related to radiosurgery. Tumor volume, tumor margin dose, or previous radiotherapy was not associated with the development of radiation-related complications. CONCLUSION Radiosurgery is an effective management strategy for many patients with meningiomas. Patients with atypical or malignant tumors exhibit high recurrence rates despite the use of radiosurgery, and these patients continue to exhibit worse cause-specific survival rates despite aggressive treatment, including surgery, external-beam radiotherapy, and radiosurgery. Further study is needed to determine the tumor control and complication rates 10 years or more after meningioma radiosurgery.
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Affiliation(s)
- S L Stafford
- Department of Radiation Oncology, Mayo Clinic and Foundation, 200 First St. SW, Rochester, Minnesota 55905, USA
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Pollock BE, Brown RD. Management of cysts arising after radiosurgery to treat intracranial arteriovenous malformations. Neurosurgery 2001; 49:259-64; discussion 264-5. [PMID: 11504101 DOI: 10.1097/00006123-200108000-00004] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The proper treatment for patients with cyst formation after arteriovenous malformation radiosurgery is unknown. METHODS The treatment of six patients who developed cysts after arteriovenous malformation radiosurgery is described. Four patients had undergone gamma knife radiosurgery (two patients developed cysts after repeat procedures), and two patients had undergone linear accelerator-based radiosurgery. The median prescription isodose volume at the time of the first radiosurgical procedure was 13.2 cm3 (range, 8.0-28.7 cm3). RESULTS The cysts were discovered a median of 48 months (range, 24-89 mo) after radiosurgery. Three patients were originally without symptoms, and observation with serial imaging was performed; two of those patients developed symptoms 13 and 40 months later, whereas one patient has remained without symptoms for 51 months. Initial treatments for patients with symptomatic cysts included cyst aspiration (n = 3) and placement of a cystoperitoneal shunt (CPS) (n = 2). The median cyst volume was 14 cm3 (range, 4-63 cm3). Cyst recurrence occurred within 2 months for patients who underwent aspiration alone, necessitating placement of a CPS. Shunt placement eliminated the cysts for four patients, at a median follow-up time of 16 months (range, 9-27 mo). One patient's cyst persisted despite CPS placement, and cyst excision was performed. No morbidity occurred with any of the cyst treatments. CONCLUSION Cyst formation after arteriovenous malformation radiosurgery may occur many years after the procedure. Although most symptomatic cysts can be effectively treated with CPSs, cyst excision may be necessary if the mass effect is not relieved with the less invasive approach.
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Affiliation(s)
- B E Pollock
- Department of Neurologic Surgery, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA.
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Pollock BE, Brown RD. Management of Cysts Arising after Radiosurgery to Treat Intracranial Arteriovenous Malformations. Neurosurgery 2001. [DOI: 10.1227/00006123-200108000-00004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Maher CO, Pollock BE. Radiation induced vascular injury after stereotactic radiosurgery for trigeminal neuralgia: case report. SURGICAL NEUROLOGY 2000; 54:189-93. [PMID: 11077103 DOI: 10.1016/s0090-3019(00)00266-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Stereotactic radiosurgery is increasingly used for the treatment of medically unresponsive trigeminal neuralgia. CASE DESCRIPTION We present the case of a 69-year-old man with trigeminal neuralgia who underwent stereotactic radiosurgery after a failed balloon compression procedure. The radiosurgery also failed to provide the patient with any significant pain relief, and microvascular decompression of the trigeminal nerve was performed 10 months later. At operation, two adjacent veins and the superior cerebellar artery were noted to have focal changes consistent with atheromatous disease. CONCLUSION We postulate that the recent radiation exposure resulted in the observed vascular injury. As a result, patients having trigeminal neuralgia radiosurgery need to be followed carefully for possible delayed ischemic events secondary to radiation-induced vascular injury.
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Affiliation(s)
- C O Maher
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Lindqvist M, Karlsson B, Guo WY, Kihlström L, Lippitz B, Yamamoto M. Angiographic Long-term Follow-up Data for Arteriovenous Malformations Previously Proven to Be Obliterated after Gamma Knife Radiosurgery. Neurosurgery 2000. [DOI: 10.1227/00006123-200004000-00006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Lindqvist M, Karlsson B, Guo WY, Kihlström L, Lippitz B, Yamamoto M. Angiographic long-term follow-up data for arteriovenous malformations previously proven to be obliterated after gamma knife radiosurgery. Neurosurgery 2000; 46:803-8; discussion 809-10. [PMID: 10764252 DOI: 10.1097/00006123-200004000-00006] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To investigate whether angiograms obtained 2 years after radiosurgery, proving total arteriovenous malformation (AVM) occlusion, represent the final state of treated AVMs and adjacent normal vessels. METHODS Angiograms were obtained for 48 patients 5 to 24 years after gamma knife radiosurgery and 4 to 17 years after the AVMs had been proven to be totally occluded after the treatment; changes in normal vessels and signs of recanalization were recorded. Ten of the patients developed clinical symptoms attributable to the AVMs or the treatment after having been declared cured, whereas the other patients did not exhibit symptoms. RESULTS There was evidence of AVM nidi at the sites of previously occluded AVMs for two patients and of nidi adjacent to those sites for another two patients. Three of the four recurrent AVMs were associated with hemorrhaging. All patients who experienced hemorrhaging from previously occluded AVMs were < or = 14 years of age at the time of gamma knife radiosurgery. There were signs of segmental narrowing in normal vessels that had been irradiated with high doses (nine patients) or a low dose (one patient). The segmental narrowing decreased with time for four of these patients, was unchanged for four, and increased for two. These vascular changes did not produce clinical symptoms in any of the patients. CONCLUSION There is a small possibility that AVMs may reappear after having been totally occluded after radiosurgery, especially in pediatric patients. Segmental narrowing in normal arteries after radiosurgery is a benign condition that rarely progresses and does not produce clinical symptoms.
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Affiliation(s)
- M Lindqvist
- Department of Neuroradiology, Karolinska Hospital, Stockholm, Sweden
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O'Connor MM, Mayberg MR. Effects of radiation on cerebral vasculature: a review. Neurosurgery 2000; 46:138-49; discussion 150-1. [PMID: 10626944 DOI: 10.1093/neurosurgery/46.1.138] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Radiation therapy plays a critical role in the treatment of central nervous system neoplasms and cerebral arteriovenous malformations. The deleterious effects of radiation on cerebral arteries may be the primary limitation to these treatment methods, as radiation may cause a variety of cerebrovascular injuries and hemodynamic changes. Radiation-induced changes in the cerebral arterial wall are determined by a number of cellular processes in endothelium and smooth muscle cells that modulate differences in radiosensitivity and phenotypic expression. The histopathological findings in arterial radiation injury include vessel wall thickening, thrombosis, luminal occlusion, and occasional telangiectases. Mechanisms for radiation injury to blood vessels include phenotypic changes in normal vessel wall cells (especially endothelium) manifested by the expression or suppression of specific gene and protein products that affect cell cycle progression or cellular proliferation or demise via cytotoxic injury or apoptosis. This review describes the molecular and cellular events involved in the systemic and cerebral vascular response to radiation and the potential means by which these responses may be influenced to augment the therapeutic effects of radiation while minimizing the untoward consequences.
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Affiliation(s)
- M M O'Connor
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, USA
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Pollock BE, Nichols DA, Garrity JA, Gorman DA, Stafford SL. Stereotactic radiosurgery and particulate embolization for cavernous sinus dural arteriovenous fistulae. Neurosurgery 1999; 45:459-66; discussion 466-7. [PMID: 10493367 DOI: 10.1097/00006123-199909000-00008] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To evaluate the safety and efficacy of stereotactic radiosurgery, either with or without transarterial embolization, in the treatment of patients with dural arteriovenous fistulae (DAVFs) of the cavernous sinus. METHODS We reviewed the findings, from a prospectively established database, for 20 patients with cavernous sinus DAVFs who were treated with either radiosurgery alone (n = 7) or radiosurgery and transarterial embolization (n = 13) in a 7-year period. The median follow-up period after radiosurgery was 36 months (range, 4-59 mo). RESULTS Nineteen of 20 patients (95%) experienced improvement of their clinical symptoms. Fourteen of 15 patients (93%) experienced either total (n = 13) or nearly total (n = 1) obliteration of their DAVFs, as documented by angiography performed a median of 12 months after radiosurgery. No patient experienced a recurrence of symptoms after angiography showed DAVF obliteration. Two patients developed new neurological deficits after embolization procedures. One patient exhibited temporary aphasia secondary to a venous infarction; another patient exhibited permanent VIth cranial nerve weakness related to acute cavernous sinus thrombosis. Two patients experienced recurrent symptoms and underwent repeat transarterial embolization at 7 and 12 months; both patients achieved clinical and angiographic cures (5 and 10 mo later, respectively). One patient experienced recurrent visual symptoms and underwent transvenous embolization 4 months after radiosurgery. CONCLUSION Staged radiosurgery and transarterial embolization provided both rapid symptom relief and long-term cures for patients with cavernous sinus DAVFs. Radiosurgery alone was effective for patients with DAVFs whose arterial supply was not accessible via a transarterial approach, although the time course of symptom improvement was longer, compared with patients who also underwent embolization.
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Affiliation(s)
- B E Pollock
- Department of Neurological Surgery, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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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. A multi-institutional analysis of complication outcomes after arteriovenous malformation radiosurgery. Int J Radiat Oncol Biol Phys 1999; 44:67-74. [PMID: 10219796 DOI: 10.1016/s0360-3016(98)00518-5] [Citation(s) in RCA: 193] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To better understand radiation complications of arteriovenous malformation (AVM) radiosurgery and factors affecting their resolution. METHODS AND MATERIALS AVM patients (102/1255) who developed neurological sequelae after radiosurgery were studied. The median AVM marginal dose (Dmin) was 19 Gy (range: 10-35). The median volume was 5.7 cc (range: 0.26-143). Median follow-up was 34 months (range: 9-140). RESULTS Complications consisted of 80/102 patients with evidence of radiation injury to the brain parenchyma (7 also with cranial nerve deficits, 12 also with seizures, 5 with cyst formation), 12/102 patients with isolated cranial neuropathies, and 10/102 patients with only new or worsened seizures. Severity was classified as minimal in 39 patients, mild in 40, disabling in 21, and fatal in 2 patients. Symptoms resolved completely in 42 patients for an actuarial resolution rate of 54% +/- 7% at 3 years post-onset. Multivariate analysis identified significantly greater symptom resolution in patients with no prior history of hemorrhage (p = 0.01, 66% vs. 41%), and in patients with symptoms of minimal severity: headache or seizure as the only sequelae of radiosurgery (p < 0.0001, 88% vs. 34%). CONCLUSION Late sequelae of radiosurgery manifest in varied ways. Further long-term studies of these problems are needed that take into account symptom severity and prior hemorrhage history.
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Yamamoto M, Hara M, Ide M, Ono Y, Jimbo M, Saito I. Radiation-related adverse effects observed on neuro-imaging several years after radiosurgery for cerebral arteriovenous malformations. SURGICAL NEUROLOGY 1998; 49:385-97; discussion 397-8. [PMID: 9537656 DOI: 10.1016/s0090-3019(97)00531-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND To our knowledge, there are no reported arteriovenous malformation (AVM) series in which detailed long-term follow-up results after radiosurgery were described based on the whole patient group. METHOD We performed a detailed long-term follow-up study of 53 patients with cerebral AVMs treated with gamma knife (GK) radiosurgery, with emphasis on radiation-related adverse effects detected on neuro-imaging after a long post-irradiation latency period (3-10 years). The post-GK follow-up period was 40-232 months excluding two mortalities, the mean being 112 and the median being 111 months. RESULTS Three patients (5.6%) have, as yet, refused all neuro-imaging follow-up studies. Complete nidus obliteration was confirmed angiographically in 32 patients (60.4%) between 1 and 5 post-GK years. In the other 18 patients (34%), despite significant nidus shrinkage being angiographically demonstrated, complete obliteration was not achieved during a 2-7 year follow-up period. There were two mortalities, one AVM-related (massive re-bleeding during the latency period) and the other angiography-related. There were five radiation-related morbidities (9.4%), three of which-hemi-Parkinson syndrome, hemiparesis, and visual field disturbances attributable to delayed cyst formation-manifested at 5.5, 7 and 7 post-GK years, respectively. We also experienced five patients (9.4%) in whom, despite remaining asymptomatic to date, radiation-related adverse effects were seen on neuro-imaging: middle cerebral artery stenosis at 3 post-GK years in one patient; dural arteriovenous fistula at 7 post GK-years in one; delayed cyst formation in two, at 5 and 10 post-GK years; and a small cavitation at 9 post-GK years. CONCLUSION Long-term follow-up, particularly with neuro-imaging modalities, is essential even after the "treatment goal" has been attained.
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Affiliation(s)
- M Yamamoto
- Department of Neurosurgery, Tokyo Women's Medical College Dai-ni Hospital, Japan
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Yamamoto M, Ban S, Ide M, Jimbo M. A diffuse white matter ischemic lesion appearing 7 years after stereotactic radiosurgery for cerebral arteriovenous malformations: case report. Neurosurgery 1997; 41:1405-9. [PMID: 9402594 DOI: 10.1097/00006123-199712000-00036] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE AND IMPORTANCE Little information is available about radiation-induced complications occurring more than 5 years after radiosurgical treatment for arteriovenous malformations. CLINICAL PRESENTATION We present a patient with arteriovenous malformations who experienced hemimotor weakness caused by a diffuse white matter necrotic lesion developing 7 years after gamma knife radiosurgery. The original nidus had been too large (24.1 cm3) to be totally covered and irradiated with a peripheral dose of 20 to 25 Gy. Therefore, the lower half of the nidus, which was adjacent to the major feeding artery, had been partially covered with a 30% isodose volume using two target points with an 18-mm collimator. A central dose of 70 Gy was used to obtain 21 Gy at the periphery. Complete nidus obliteration was angiographically confirmed 38 months after radiosurgery. After a 6-year uncomplicated period, this patient experienced a convulsive seizure and then mild right hemiparesis. INTERVENTION Computed tomography demonstrated a diffuse hypodense area in the left white matter, which had not been revealed by the previous examination. With steroid treatment, this patient achieved clinical improvement, although there was no significant improvement in the computed tomography-demonstrated white matter lesion. CONCLUSION Although the evaluation of this patient may not be sufficient and further examinations may be necessary, we tentatively conclude that the computed tomography-demonstrated hypodense lesion in this patient is a radiation-related necrotic lesion. Long-term follow-up is crucial, even after the "treatment goal" has been achieved.
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Affiliation(s)
- M Yamamoto
- Department of Neurosurgery, Tokyo Women's Medical College Dai-ni Hospital, Japan
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