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. 2023 Oct 16;6(16):CASE23392.
doi: 10.3171/CASE23392. Print 2023 Oct 16.

Symptomatic radionecrosis after postoperative but not preoperative stereotactic radiosurgery in a single patient: illustrative case

Bryce J Laurin  1 , Michael Straza  2 , George Noid  2 , Jennifer M Connelly  3 , Wade M Mueller  4 , Joseph Bovi  2   4 , Max O Krucoff  4   5
Affiliations

Symptomatic radionecrosis after postoperative but not preoperative stereotactic radiosurgery in a single patient: illustrative case

Bryce J Laurin et al. J Neurosurg Case Lessons. .

Abstract

Background: Standard of care for brain metastases involves stereotactic radiosurgery (SRS). For cases that also require surgery because of lesion size, edema, or neurological symptoms, whether to provide pre- or postoperative SRS has become a prevalent debate.

Observations: Herein, the unique case of a patient with brain metastases of the same pathology and similar size in two different brain locations at two different times is described. The patient underwent surgery with preoperative SRS for the first lesion and surgery with postoperative SRS for the second lesion. Although both treatments resulted in successful local control, the location that received postoperative SRS developed symptomatic and rapidly progressive radiation necrosis (RN) requiring a third craniotomy.

Lessons: Large randomized controlled trials are ongoing to compare pre- versus postoperative SRS for the treatment of symptomatic brain metastases (e.g., study NRG-BN012). Recent interest in preoperative SRS has emerged from its theoretical potential to decrease rates of postoperative RN and leptomeningeal disease. This valuable case in which both therapies were applied in a single patient with a single pathology and similar lesions provides evidence supportive of preoperative SRS.

Keywords: SRS; brain metastases; neurosurgery; neurosurgical oncology; recurrence.

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Conflict of interest statement

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Figures

FIG. 1
FIG. 1
Preoperative (A–C) and postoperative (D–F) MRI of the right frontal metastasis. Axial precontrast T1-weighted (A), postcontrast T1-weighted (B), and fluid-attenuated inversion recovery (FLAIR; C) MRI depicting a right frontal lesion. Axial precontrast T1-weighted (D), postcontrast T1-weighted (E), and FLAIR (F) MRI depicting the resection cavity 24 hours postoperatively. Green arrow - tumor location (B) and corresponding resection cavity (E).
FIG. 2
FIG. 2
Preoperative (A–C) and postoperative (D–F) MRI of the left frontal metastasis. Axial precontrast T1-weighted (A), postcontrast T1-weighted (B), and FLAIR (C) MRI depicting the left frontal lesion. Axial precontrast T1-weighted (D), postcontrast T1-weighted (E), and FLAIR (F) MRI depicting the resection cavity 24 hours postoperatively. Green arrow - tumor location (B) and corresponding resection cavity (E).
FIG. 3
FIG. 3
SRS treatment plans for the right and left frontal lesions. Axial (A), sagittal (B), and coronal (C) postcontrast T1-weighted MRI depicting the preoperative SRS treatment plan for the right frontal lesion. Axial (D), sagittal (E), and coronal (F) postcontrast T1-weighted MRI depicting the postoperative SRS treatment plan for the left frontal resection cavity. Note that despite the similar size of the lesions, the size of the treatment field is larger in the postoperative plan because of planning around a resection cavity rather than a lesion.
FIG. 4
FIG. 4
Progressive symptomatic RN of the left frontal lesion site. Axial precontrast T1-weighted (A), postcontrast T1-weighted (B), FLAIR (C), and relative cerebral blood volume (D) MRI sequences depicting initial progression of posttreatment RN. Axial precontrast T2-weighted (E), postcontrast T1-weighted (F), and FLAIR (G) MRI sequences depicting further progression of left frontal RN 25 days later. Axial precontrast T1-weighted (H), postcontrast T1-weighted (I), and FLAIR (J) MRI sequences depicting the postoperative resection cavity 24 hours after secondary left frontal craniotomy for resection of the symptomatic RN.
See this image and copyright information in PMC

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