Malignant Brain Oedema after Radiosurgery of a Medium-sized Vestibular Schwannoma

Abstract

Case Report: We present a patient with an unusual malignant brain oedema occurring after gamma knife radiosurgery of a medium-sized vestibular schwannoma.

Clinical presentation: A 62-year-old female with a large vestibular schwannoma underwent partial microsurgical resection; 6 months later she underwent a second intervention with gamma knife radiosurgery for a medium-sized tumour remnant. With a latency period of 6 months after radiosurgery, she presented with progressive neurological deterioration. Serial magnetic resonance imaging revealed progression of the tumour and of the perifocal oedema which finally extended up to the ipsilateral internal capsule. The patient became comatose.

Intervention: The tumour was nearly completely removed via a standard retrosigmoid craniotomy. Histopathological examination demonstrated increased mitotic activity compared to the initial histology. The patient became conscious 10 days after surgery and recovered slowly. Surprisingly, the brain oedema resolved rapidly. The CT scan obtained 11 days after surgery showed almost complete disappearance of the oedema.

Conclusion: Although rare, radiosurgery of medium-sized vestibular schwannomas causing brainstem compression may lead to life-threatening tumour progression and malignant brain oedema. Therefore, microsurgical gross total resection should be the preferred treatment option in vestibular schwannomas causing significant brainstem compression.

malignant brain oedema - vestibular schwannoma - radiosurgery - gamma knife

References

• 1 Couldwell WT, Mohan AL. Enlargement of a vestibular schwannoma after stereotactic radiotherapy.  Acta Neurochir (Wien). 2002;  144 1319-1322
• 2 Friedman WA, Foote KD. Linear accelerator-based radiosurgery for vestibular schwannoma.  Neurosurg Focus. 2003;  14 e2
• 3 Ganslandt O, Fahrig A, Strauss C. Hemorrhage into cystic vestibular schwannoma following stereotactic radiation therapy.  Zentralbl Neurochir. 2008;  69 ((4)) 204-206
• 4 Gardner G, Robertson JH. Hearing preservation in unilateral acoustic neuroma surgery.  Ann Otol Rhinol Laryngol. 1988;  97 ((1)) 55-66
• 5 Hasegawa T, Kida Y, Yoshimoto M. et al . Evaluation of tumor expansion after stereotactic radiosurgery in patients harboring vestibular schwannomas.  Neurosurgery. 2006;  58 1119-1128
• 6 Ho SY, Kveton JF. Rapid growth of acoustic neuromas after stereotactic radiotherapy in type 2 neurofibromatosis.  Ear Nose Throat J. 2002;  81 831-833
• 7 Kan P, Liu JK, Wendland MM. et al . Peritumoral edema after stereotactic radiosurgery for intracranial meningiomas and molecular factors that predict its development.  J Neurooncol. 2007;  83 33-38
• 8 Karampelas I, Alberico RA, Plunkett RJ. et al . Intratumoral hemorrhage after remote subtotal microsurgical resection and gamma knife radiosurgery for vestibular schwannoma.  Acta Neurochir (Wien). 2007;  149 313-316
• 9 Kondziolka D, Lunsford LD, McLaughlin MR. et al . Long-term outcomes after radiosurgery for acoustic neuromas.  N Engl J Med. 1998;  339 1426-1433
• 10 Kondziolka D, Lunsford LD, Flickinger JC. Acoustic neuroma radiosurgery. Origins, contemporary use and future expectations.  Neurochirurgie. 2004;  50 427-435
• 11 Kondziolka D, Subach BR, Lunsford LD. et al . Outcomes after gamma knife radiosurgery in solitary acoustic tumors and neurofibromatosis Type 2.  Neurosurg Focus. 1998;  5 e2
• 12 Maire JP, Huchet A, Milbeo Y. et al . Twenty years’ experience in the treatment of acoustic neuromas with fractionated radiotherapy: a review of 45 cases.  Int J Radiat Oncol Biol Phys. 2006;  66 ((1)) 170-178
• 13 McEvoy AW, Kitchen ND. Rapid enlargement of a vestibular schwannoma following gamma knife treatment.  Minim Invasive Neurosurg. 2003;  46 254-256
• 14 Mendenhall WM, Friedman WA, Buatti JM. et al . Preliminary results of linear accelerator radiosurgery for acoustic schwannomas.  J Neurosurg. 1996;  85 1013-1019
• 15 Nakamura S, Hiyama H, Arai K. et al . Gamma knife radiosurgery for meningiomas: four cases of radiation-induced edema.  Stereotact Funct Neurosurg. 1996;  66 ((Suppl. 1)) 142-145
• 16 Neuhaus O, Saleh A, van OA. et al . Cerebellar infarction after gamma knife radiosurgery of a vestibular schwannoma.  Neurology. 2007;  68 590
• 17 Paddick I, Lippitz B. A simple dose gradient measurement tool to complement the conformity index.  J Neurosurg. 2006;  105 ((Suppl)) 194-201
• 18 Pollack AG, Marymont MH, Kalapurakal JA. et al . Acute neurological complications following gamma knife surgery for vestibular schwannoma. Case report.  J Neurosurg. 2005;  103 546-551
• 19 Pollock BE, Lunsford LD, Flickinger JC. et al . Vestibular schwannoma management. Part I. Failed microsurgery and the role of delayed stereotactic radiosurgery.  J Neurosurg. 1998;  89 944-948
• 20 Pollock BE, Lunsford LD, Kondziolka D. et al . Vestibular schwannoma management. Part II. Failed radiosurgery and the role of delayed microsurgery.  J Neurosurg. 1998;  89 949-955
• 21 Regis J, Pellet W, Delsanti C. et al . Functional outcome after gamma knife surgery or microsurgery for vestibular schwannomas.  J Neurosurg. 2002;  97 1091-1100
• 22 Roche PH, Regis J, Deveze A. et al . Surgical removal of unilateral vestibular schwannomas after failed gamma knife radiosurgery.  Neurochirurgie. 2004;  50 383-393
• 23 Schaller C, Liefner M, Ansari S. et al . Operation for delayed symptomatic brain oedema after treatment of an arteriovenous malformation by embolization and radiosurgery.  Acta Neurochir (Wien). 2005;  147 1103-1108
• 24 Shamisa A, Bance M, Nag S. et al . Glioblastoma multiforme occurring in a patient treated with gamma knife surgery. Case report and review of the literature.  J Neurosurg. 2001;  94 816-821
• 25 Shin M, Ueki K, Kurita H. et al . Malignant transformation of a vestibular schwannoma after gamma knife radiosurgery.  Lancet. 2002;  360 309-310
• 26 Shuto T, Inomori S, Matsunaga S. et al . Microsurgery for vestibular schwannoma after gamma knife radiosurgery.  Acta Neurochir (Wien). 2008;  150 229-234
• 27 Son EI, Kim IM, Kim SP. Vestibular schwannoma with malignant transformation: a case report.  J Korean Med Sci. 2001;  16 ((6)) 817-821
• 28 Thomsen J, Mirz F, Wetke R. et al . Intracranial sarcoma in a patient with neurofibromatosis type 2 treated with gamma knife radiosurgery for vestibular schwannoma.  Am J Otol. 2000;  21 364-370
• 29 van Eck AT, Horstmann GA. Increased preservation of functional hearing after gamma knife surgery for vestibular schwannoma.  J Neurosurg. 2005;  102 ((Suppl)) 204-206
• 30 Watanabe T, Saito N, Hirato J. et al . Facial neuropathy due to axonal degeneration and microvasculitis following gamma knife surgery for vestibular schwannoma: a histological analysis.  Case report. J Neurosurg. 2003;  99 916-920
• 31 Wowra B, Muacevic A, Jess-Hempen A. et al . Outpatient gamma knife surgery for vestibular schwannoma: definition of the therapeutic profile based on a 10-year experience.  J Neurosurg. 2005;  102 ((Suppl)) 114-118

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