Delayed radiation necrosis of the brain

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✓ The cases of six patients are presented to delineate the clinical profile of delayed radiation necrosis of the brain. In five the diagnosis was verified histologically. Symptoms most often begin 9 months to 2 years after radiotherapy. Progressive visual impairment and dementia are common following perisellar irradiation, while hemispheric signs predominate following irradiation of the cerebrum. Cerebrospinal fluid protein may be elevated. Focal delta slowing is usually present on electroencephalography. The necrotic brain may appear on radionuclide brain scan as an area of abnormal uptake and also act as an avascular space-occupying lesion. With computerized tomography, radiation necrosis appears as an intracerebral area with diminished absorption coefficient that is often enhanced with intravenous contrast medium. The syndrome may be sufficiently characteristic to eliminate the need for surgical exploration and biopsy in some cases. Cumulative experience suggests that the risk-to-benefit ratio of radiotherapy becomes increasingly unfavorable for most patients with benign intracranial neoplasms when the standard brain tumor dose of 5000 to 7000 rads is fractionated at greater than 200 rads per day.

Article Information

Address reprint requests to: Albert N. Martins, M.D., Neurosurgery Service, Walter Reed Army Medical Center, Washington, D.C. 20012.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Computerized tomography scan. Areas with diminished absorption coefficient in left temporal lobe and cerebellar hemisphere were not enhanced after an intravenous injection of contrast medium.

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    Case 2. Left carotid angiogram 13 months after radiotherapy shows a large avascular frontal mass that was not present on a subsequent angiogram performed 20 months later.

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    Case 3. Computerized tomography scan. Bilateral frontal areas with diminished absorption coefficient were enhanced after an intravenous injection of contrast medium, the one on the left appearing with a distinct “ring-blush.”

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    Case 5. Computerized tomography scans. Left: Before enhancement. Irregular frontal areas with diminished absorption coefficient, more extensive on the right. Right: After enhancement, “ring-blush” in the right frontal lobe.

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    Photomicrographs showing the characteristic histological changes of delayed radiation necrosis of the brain. Upper Left: Thickened hyalinized vessels (AFIP Neg. No. 76–4132). H & E, ×165. Upper Right: Necrotic parenchyma surrounding vessels (arrow) undergoing fibrinoid necrosis (AFIP Neg. No. 76–3789). H & E, ×115. Lower Left: Intracerebral perivascular hemorrhage (AFIP Neg. No. 76–6434). H & E, ×28.

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    Pathogenesis of radiation necrosis. The postulated sequence of events incited by radiation.

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