CASE 9912 Published on 19.03.2012
0

Delayed intracerebral haemorrhage after cyberknife radiosurgery: case report and review of the literature

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Finitsis S, Metaxas F, Michailidou M, Metaxa L, Drevelengas A

*corresponding author: Metaxa Linda lindamet25@gmail.com,
Finitsis Stefanos AHEPA Hospital Thessaloniki,
Metaxas Feidias AHEPA Hospital Thessaloniki,
Michailidou Maria AHEPA Hospital Thessaloniki,
Metaxa Linda AHEPA Hospital Thessaloniki,
Drevelengas Antonios AHEPA Hospital Thessaloniki
Connected authors
Linda Metaxa UNITED KINGDOM
Patient

25 years, female

Categories
Area of Interest Neuroradiology brain, Oncology, Vascular ; Imaging Technique MR, CT, Catheter arteriography
Download as PDF Print Show related cases Notify admin
Clinical History
A 25- year-old woman was admitted to the outpatient department of our hospital with blurred vision, mydriasis, orbitocele, right paresis of the trochlear nerve, strabism and diplopia upon blinking of her eyes.
Imaging Findings
A CT and MRI revealed an avidly enhancing mass originated from the ipsilateral cavernous sinus, surrounded and compressed the pons and the mesencephalon from the right side [Fig. 1].
Based on these findings, a partial surgical excision of the tumour was performed. The pathologic examination revealed a meningioma. Complete removal of the mass was not attempted because of optic nerve and internal carotid artery infiltration.
The patient was followed up annually with MRI.
Three years later the tumour diameter had increased to 3 cm [Fig. 2] and so 3 Cyberknife sessions were performed with 21 Gray delivered to the 80% isodose line.
Three years later the patient presented worsening headaches and gradual loss of cognitive function. A CT revealed intracranial haemorrhage with intraventricular extension [Fig. 3]. Selective angiography showed a peritumoral venous aneurysm [Fig. 4]. The patient was managed conservatively.
18 months later, a CT revealed again an increase of the tumour size [Fig. 5].
Discussion
Complications related to stereotactic radiosurgery (SRS) of meningiomas usually depend on tumour location, volume and the radiation dose. The immediate complications include nausea, headaches, hemiparesis [1] related to tumour size and the vascular involvement, optic neuropathy [2, 3], oedema [1, 4, 5] not related to the tumour size or radiation dose, cranial nerve deficits [3, 6, 7], internal carotid artery stenosis, stroke, haemorrhage and cyst formation [2, 8-10].

Complications of SRS are reported in 3-40% of cases, being represented by either transient (3.0%) or permanent complications (5.0%) [11].
In a series of 1045 intracranial meningiomas treated with SRS, morbidity was 7.7%, including visual deterioration, 6th nerve palsy, and trigeminal neuropathy [12].

Vascular complications following SRS, include vessel occlusion and haemorrhage which are rare, occurring 1.1-2.3% of the time. Vascular occlusion occurs in a delayed fashion, usually 14-60 months after treatment [13]. Haemorrhage post SRS occurs 1-8 years after treatment. However, Feng-Wen Su revealed a case of acute haemorrhage after SRS for meningioma [14]. The association between radiation and tumour/cerebral haemorrhage remains controversial and is likely mostly related to rapid postradiation tumour shrinkage leading to mechanical strain on vascular structures, rather than to histological changes intrinsic to the vasculature. Other authors suggest that the haemorrhage comes as a result of rupture of the brain vessels [15-17] due to wall necrosis.
Spontaneous bleeding occurs in 1.3-2.4% of meningiomas [18]. Kim DG PC has theorised that thrombosis, oedema, vessel erosion, and rapid tumour growth lead to tumour infarction. As tumour infarction progresses, the intratumoral pressure increases and rupture of the peritumoral vessel eventually occurs [19].
There are only few reports of delayed meningioma bleeding after GKR in the literature. Five cases of delayed (1-8y after GKR) tumoral haemorrhage that had undergone GKR for intracranial tumours have been reported [20]. In a series of 173 meningiomas, Kwon et al. reported four cases of ICH between 2-8 years after GKR. Similarly Kim et al. reported a case of delayed bleeding after gamma knife surgery for meningioma. Conversely, Singh VP et al. conducted a study of 306 patients with cavernous sinus meningioma 77 of which underwent GKR. In this study none of the patients presented complications with intracerebral haemorrhage (ICH).
In conclusion, although considered as a very rare event, delayed ICH may occur after CRS of meningiomas. This low incidence rate may increase in the future, as the use of CRS is steadily increasing. Thus it should be taken into account when planning CRS of meningiomas.
Differential Diagnosis List
Delayed bleeding of a meningioma 3 years after cyberknife radiosurgery
Haemorrhagic meningioma
Raptured aneurysm
Final Diagnosis
Delayed bleeding of a meningioma 3 years after cyberknife radiosurgery
Case information
URL: https://www.eurorad.org/case/9912
DOI: 10.1594/EURORAD/CASE.9912
ISSN: 1563-4086
Figure 1

First MRI

First MRI
Woman, 25 years old. Axial T1 post gadolinium injection and T2 flair at the level of the mesencephalon. An enhancing mass is seen medial to uncus extending posteriorly and compressing the mesencephalon on the right.
Figure 2

Second MRI (3 years later)

Second MRI (3 years later)
Same patient as Fig. 1, three years later (after a partial surgical excision of the tumour through a frontal-temporal craniotomy). 2a. T1 post contrast 2b. FLAIR Tumour diameter has increased.
Figure 3

CT 3 years after Gamma Knife Surgery (GKS)

CT 3 years after Gamma Knife Surgery (GKS)
Same patient as Fig. 1. (6 years later) CT 3 years after Gamma Knife Surgery (GKS). Intracranial haemorrhage with intraventricular extension (delayed meningioma bleeding after GKR)
Figure 4

Selective angiography

Selective angiography
Same patient as Fig. 1 (6 years later). Selective angiography (lateral view) after the ICH was found. The black arrow shows a peritumoral venous aneurysm.
Figure 5

CT 18m after ICH

CT 18m after ICH
Same patient as Fig. 1 (7.5years later). The tumour size and morphology have changed.