Radiation-induced brain cavernomas in elderly: review of the literature and a rare case report

Abstract

Radiation-induced brain cavernomas have been mainly reported in children who underwent radiotherapy for medulloblastoma, leukemia, or low-grade glioma. Otherwise, the "de novo" appearance of a cavernoma in an elderly long-survivor patient after resection and radiotherapy of a glioblastoma is a rare event. We report the case of a 62-year-old female patient who underwent surgical resection of a right temporal glioblastoma, followed by radiation therapy of the operative field and surrounding brain and concomitant adjuvant temozolomide. Four years after the operation, a follow-up Magnetic Resonance revealed a good tumor control and a small round lesion at the superior surface of the right cerebellar hemisphere, close to the margins of the previous irradiation field. The radiological items were consistent with a cavernous angioma. Because of the small size of the malformation and the absence of related symptoms, no treatment was performed. The patient died for tumor progression 86 months after the initial operation, with unchanged cerebellar cavernoma. The occurrence of a cavernous angioma in an elderly patient after radiotherapy for brain glioblastoma is an exceptional event; the distribution of radiotherapy-induced cavernous malformations reported in current literature is presented and the mechanism of their formation is discussed.

Figure 1a.

Coronal contrast-enhanced T1 weighted image showing a large intra-axial right temporal lesion with intense and inhomogeneous contrast enhancement due to the presence of necrotic areas, strongly suggestive for a high-grade glioma. The lesion is surrounded by a large amount of perifocal oedema, with subsequent compressive effect on the right lateral ventricle and contralateral shift of the midline structures

Figure 1b.

Coronal contrast-enhanced T1 weighted image showing the presence of an area of intense enhancement in the right temporal region, peripherally to the surgical cavity, consistent with tumor recurrence

Figure 2a.

Axial T1 weighted image showing regular morphology and signal of the posterior fossa structures, with no evidence of focal lesions of the cerebellar hemispheres

Figure 2b.

Axial FLAIR image revealing surgical cavity in the right temporal region with no sign of tumor recurrence; presence of a round small lesion (transverse diameter: 1 cm) in the upper convexity of the right cerebellar hemisphere showing central hyperintensity with a rim of signal loss due to the presence of hemosiderin, consistent with CA

Figure 3.

Distribution of CNS radiotherapy-induced cavernous malformations, according to primary tumours