Brain tissue injury and necrosis after Gamma Knife and Novalis Radiosurgery for brain tumors, metastasis and AVM Konstantin Nikitin Konstantin Nikitin Department of radiotherapy & Department of radiotherapy & radiosurgery, radiosurgery, Burdenko Neurosurgical Burdenko Neurosurgical Institute, Moscow Institute, Moscow European Gamma Knife Society meeting 28 November 2009
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Brain tissue injury and necrosis after rafiosurgery (2009)
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Brain tissue injury and necrosis after Gamma Knife and Novalis
Radiosurgeryfor brain tumors, metastasis and AVM
Konstantin NikitinKonstantin NikitinDepartment of radiotherapy & Department of radiotherapy &
radiosurgery,radiosurgery,Burdenko Neurosurgical Institute, Burdenko Neurosurgical Institute,
MoscowMoscowEuropean Gamma Knife Society meeting
28 November 2009
ContentContent
► IntroductionIntroduction- incidence incidence - time of developmenttime of development- pathogenesis pathogenesis - pathologypathology- risk factors risk factors
► Severe necrosisSevere necrosis - 1 - 1,2%,2% of 760 mts or 2,4% of 377 pt of 760 mts or 2,4% of 377 pt (9 cases (9 cases after 10-MeV LINAC SRS) after 10-MeV LINAC SRS) [Valery et al, 2003][Valery et al, 2003]
► Symptomatic injurySymptomatic injury - 7% - 7% (17 of 243 pt - GK)(17 of 243 pt - GK) [Chin et al, 2001][Chin et al, 2001]
at 2 years after LINAC SRS at 2 years after LINAC SRS [[Voges et alVoges et al, , 19961996]]
► Necrotic findingsNecrotic findings in resected tissue - 33% in resected tissue - 33% (11 of 33 pt (11 of 33 pt at 1 - 11 at 1 - 11 yyeaearrs after SRS fors after SRS for AVM)AVM) [Chang et al[Chang et al, 1997, 1997]]
► 3/4 of all complications develop 3/4 of all complications develop at firstat first 14 months 14 months
from Voges et al. Int J Radiat Oncol Biol Phys 36: 1055–1063, 1996from Voges et al. Int J Radiat Oncol Biol Phys 36: 1055–1063, 1996
Development timeDevelopment time: : median - 4 months (range edian - 4 months (range 2 – 14);;Recovery time for symptoms: 7.5 months (range 2 –
16),for imaging changes - 10.5 months (6 – 16) [Chin et al, [Chin et al,
2001]2001]
Time of development and recoveryTime of development and recovery
Symptomatic injury (headache + vomiting) at 6 months, Symptomatic injury (headache + vomiting) at 6 months, relieved after 4 months of steroid therapy.relieved after 4 months of steroid therapy.
Symptomatic injury (focal seizures) at 5 monthsSymptomatic injury (focal seizures) at 5 months,, relieved with steroids and carbamazepine.relieved with steroids and carbamazepine.
MRI at 10 months MRI atMRI at 10 months MRI at 1616 monthsmonths
Novalis SRS
F F 35 35 yo. yo. SchwannomaSchwannoma 4,4 ccm; 4,4 ccm; SRSSRS 1144,,4 4 Gy - 80%.Gy - 80%.
*Exacerbation of herpes simplex infection after 6 days *Exacerbation of herpes simplex infection after 6 days with trigeminal neuralgia following 7 months.with trigeminal neuralgia following 7 months.
Symptomatic injury (deterioration of hemiparesis) at 8 Symptomatic injury (deterioration of hemiparesis) at 8 months, months,
no improvement with medications at 24 months.no improvement with medications at 24 months.
MRI at 14 monthsMRI at 14 monthsNovalis SRS
M M 53 53 yo. yo. Pilocytic astrocytomaPilocytic astrocytoma 5 ccm, 5 ccm, 119 Gy - 9 Gy - 50%.50%.
Symptomatic injury (ataxia + nausea) at 3 months,Symptomatic injury (ataxia + nausea) at 3 months, regressed with steroids after next 7 months. regressed with steroids after next 7 months.
MRI at 3 MRI at 3 monthsmonths
Gamma-knife
M 48 yo. M 48 yo. OligodendrogliomaOligodendroglioma 18 18 ccm; 18 Gy - 50%. ccm; 18 Gy - 50%.
Symptomatic injury (epilepsy + raised ICP) at 6 month, Symptomatic injury (epilepsy + raised ICP) at 6 month, ineffective steroid therapy ineffective steroid therapy,, removal of necrosis at 13 removal of necrosis at 13
months.months.
10-Gy vol > 100 10-Gy vol > 100 ccmccm
MRI at 9 monthsMRI at 9 months
Gamma-knife
M 48 yo. M 48 yo. Lung cancer mtsLung cancer mts 6,1 ccm; 6,1 ccm; 2020 Gy - 50%. Gy - 50%. Symptomatic injury (ataxia + hemianopia) at 8 month, Symptomatic injury (ataxia + hemianopia) at 8 month, symptoms relieved after 1 month of dexamethazone.symptoms relieved after 1 month of dexamethazone.
Symptomatic injury (hemiparesis + raised ICP) at 4 Symptomatic injury (hemiparesis + raised ICP) at 4 month,month,
relieved with dexamethazone (16mg) and mild relieved with dexamethazone (16mg) and mild dehydratation.dehydratation.MRI at 6MRI at 6 monthsmonths Perfusion CT Perfusion CT
CBVCBV
Gamma-knife
SummarySummary
► IncidenceIncidence of radiation injury of brain is a of radiation injury of brain is a function of SRS parameters (dose, volume, function of SRS parameters (dose, volume, selectivity, etc), target location and time of selectivity, etc), target location and time of follow-up.follow-up.
►Higher rateHigher rate with gliomas, high 10- or 12-Gy with gliomas, high 10- or 12-Gy volume of brain irradiated and longer follow-up.volume of brain irradiated and longer follow-up.
► Small radio-lesions in Small radio-lesions in eloquent structureseloquent structures can be symptomatic.can be symptomatic.
►Corticosteroid administration for complication prophylaxis in case of preexisting edema ?