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Complications of cranial stereotactic radiosurgery

INTRODUCTION

Stereotactic radiosurgery (SRS) involves the administration of a high dose of ionizing radiation in a single fraction to a small, well-demarcated benign or malignant tumor or vascular malformation within the brain parenchyma, adjacent cerebral meninges, or base of skull region. (See "Stereotactic cranial radiosurgery and radiotherapy".)

The complications of SRS differ from those of conventional fractionated cranial irradiation because SRS is restricted to a small target volume and it utilizes a much higher dose in a single fraction. The toxicity of SRS is commonly divided into acute reactions occurring within 90 days of treatment and late reactions. The Radiation Therapy Oncology Group has published a grading scale for both acute and late central nervous system (CNS) toxicity following any form of radiotherapy (table 1 and table 2).

The acute and late complications of SRS will be reviewed here, as well as specific complications associated with the most common applications of intracranial SRS. The complications of standard fractionation cranial irradiation and the results of treatment using SRS are discussed elsewhere. (See "Complications of cranial irradiation" and "Treatment of brain metastases in favorable prognosis patients" and "Vascular malformations of the central nervous system".)

ACUTE REACTIONS

The initial evaluation of the acute toxicity of SRS was derived from a dose escalation study conducted by the Radiation Therapy Oncology Group (RTOG) in 156 patients with primary (36 percent) or recurrent metastatic brain tumors (64 percent) [1,2]. In this population, the maximum tolerated doses of single fraction SRS were established as 24 Gy, 18 Gy, and 15 Gy for tumors ≤20 mm, 21 to 30 mm, and 31 to 40 mm in maximum diameter, respectively. At these dose levels, the rates of acute grade 3 to 5 CNS toxicity ranged from 0 to 17 percent in the three groups, with the higher rates in patients with larger tumors [2].

Severe — Subsequent experience based upon these tumor volume and dose recommendations suggest that severe acute reactions are rare. As an example, in one series that included 835 consecutive patients undergoing SRS, 18 had a neurologic event within seven days of treatment (eg, new focal deficit or seizure) and three died [3].
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References Top
  1. Shaw, E, Scott, C, Souhami, L, et al. Radiosurgery for the treatment of previously irradiated recurrent primary brain tumors and brain metastases: initial report of radiation therapy oncology group protocol (90-05). Int J Radiat Oncol Biol Phys 1996; 34:647.
  2. Shaw, E, Scott, C, Souhami, L, et al. Single dose radiosurgical treatment of recurrent previously irradiated primary brain tumors and brain metastases: final report of RTOG protocol 90-05. Int J Radiat Oncol Biol Phys 2000; 47:291.
  3. Chin, LS, Lazio, BE, Biggins, T, Amin, P. Acute complications following gamma knife radiosurgery are rare. Surg Neurol 2000; 53:498.
  4. Gelblum, DY, Lee, H, Bilsky, M, et al. Radiographic findings and morbidity in patients treated with stereotactic radiosurgery. Int J Radiat Oncol Biol Phys 1998; 42:391.
  5. Werner-Wasik, M, Rudoler, S, Preston, PE, et al. Immediate side effects of stereotactic radiotherapy and radiosurgery. Int J Radiat Oncol Biol Phys 1999; 43:299.
  6. Murphy, MJ, Chang, SD, Gibbs, IC, et al. Patterns of patient movement during frameless image-guided radiosurgery. Int J Radiat Oncol Biol Phys 2003; 55:1400.
  7. Takeuchi, H, Yoshida, M, Kubota, T, et al. Frameless stereotactic radiosurgery with mobile CT, mask immobilization and micro-multileaf collimators. Minim Invasive Neurosurg 2003; 46:82.
  8. Kamath, R, Ryken, TC, Meeks, SL, et al. Initial Clinical Experience With Frameless Radiosurgery For Patients With Intracranial Metastases. Int J Radiat Oncol Biol Phys 2005; 61:1467.
  9. Plowman, PN. Stereotactic radiosurgery. VIII. The classification of postradiation reactions. Br J Neurosurg 1999; 13:256.
  10. Flickinger, JC, Lunsford, LD, Kondziolka, D, et al. Radiosurgery and brain tolerance: an analysis of neurodiagnostic imaging changes after gamma knife radiosurgery for arteriovenous malformations. Int J Radiat Oncol Biol Phys 1992; 23:19.
  11. Flickinger, JC, Kondziolka, D, Lunsford, LD, et al. A multi-institutional analysis of complication outcomes after arteriovenous malformation radiosurgery. Int J Radiat Oncol Biol Phys 1999; 44:67.
  12. Stafford, SL, Pollock, BE, Foote, RL, et al. Meningioma radiosurgery: tumor control, outcomes, and complications among 190 consecutive patients. Neurosurgery 2001; 49:1029.
  13. Kondziolka, D, Levy, EI, Niranjan, A, et al. Long-term outcomes after meningioma radiosurgery: physician and patient perspectives. J Neurosurg 1999; 91:44.
  14. Likhterov, I, Allbright, RM, Selesnick, SH. LINAC radiosurgery and radiotherapy treatment of acoustic neuromas. Otolaryngol Clin North Am 2007; 40:541.
  15. Foote, KD, Friedman, WA, Buatti, JM, et al. Analysis of risk factors associated with radiosurgery for vestibular schwannoma. J Neurosurg 2001; 95:440.
  16. Lunsford, LD, Niranjan, A, Flickinger, JC, et al. Radiosurgery of vestibular schwannomas: summary of experience in 829 cases. J Neurosurg 2005; 102 Suppl:195.
  17. Kano, H, Kondziolka, D, Khan, A, et al. Predictors of hearing preservation after stereotactic radiosurgery for acoustic neuroma. J Neurosurg 2009; 111:863.
  18. Petrovich, Z, Yu, C, Giannotta, SL, et al. Survival and pattern of failure in brain metastasis treated with stereotactic gamma knife radiosurgery. J Neurosurg 2002; 97:499.
  19. Andrews, DW, Scott, CB, Sperduto, PW, et al. Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial. Lancet 2004; 363:1665.
  20. Balasubramaniam, A, Shannon, P, Hodaie, M, et al. Glioblastoma multiforme after stereotactic radiotherapy for acoustic neuroma: Case report and review of the literature. Neuro Oncol 2007; 9:447.
  21. Sheehan, J, Yen, CP, Steiner, L. Gamma knife surgery-induced meningioma. Report of two cases and review of the literature. J Neurosurg 2006; 105:325.
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