Spontaneous haemorrhage into metastatic brain tumours after stereotactic radiosurgery using a linear accelerator

Abstract

Objective: To determine the incidence and clinical characteristics of spontaneous haemorrhage into metastatic brain tumours after radiosurgery. Methods: Intratumour haemorrhage rate, clinical features, and treatment were evaluated in 54 patients with 131 brain metastases of varying origin who were treated using linear accelerator radiosurgery. The marginal dose was maintained constant at 20 or 25 Gy, irrespective of tumour size. Results: Haemorrhage was identified in 7.4% of the metastases (five tumours in four patients) before radiosurgery and in 18.5% (10 tumours in 10 patients) after radiosurgery. In three cases, haemorrhage into the tumour after radiosurgery was symptomatic. Half the haemorrhages occurred within one month of radiosurgery. The changes in tumour size observed at the time of haemorrhage were an increase in one tumour, no change in five, and a decrease in four. Haemorrhage into a tumour after radiosurgery was more likely to occur in female patients, in tumours with a larger volume on pretreatment neuroimaging, and in tumours treated with a larger number of isocentres or a higher maximum dose. Haemorrhagic features in the patients or their tumours on presurgical assessment were not disposing factors to haemorrhage after radiosurgery. Conclusions: When larger brain metastases are aggressively treated by radiosurgery, better local control may be attained but there may also be a higher risk of haemorrhage soon after the treatment.

Microhemorrhage, a possible mechanism for cyst formation in vestibular schwannomas

“…9,24 Recently, Suzuki, et al, 27 suggested that radiosurgery is a contributing factor for spontaneous intratumoral hemorrhage. They concluded that radiosurgery may cause the hemorrhages, which occur at relatively short intervals after treatment, and they proposed the following mechanisms: 1) thrombosis induced by cytokines produced by irradiated endothelial cells; 2) increase in intravascular outflow resistance due to radiation-induced venous obliteration; and 3) necrosis in the tumor and blood flow congestion in residual neoplastic tissue.…”

Intracochlear Hemorrhage After Gamma Knife Radiosurgery

“…The only predisposing factor was GKRS performed 24 hours before presentation. Many cases of intratumoral or peritumoral hemorrhage in the literature were associated with meningiomas (33) or brain metastases (24,36). However, some bleeding was spontaneous, and GKRS cannot be the only cause of this complication.…”

“…The biological effect of SRS is early direct injury to the tumor cells and then late injury to the tumor vasculature within the high-dose target volume (24). Some of these effects can directly interfere with peripheral structures such as the nerves, vessels, and nuclei, whereas other side effects are indirectly caused by the immediate and slowly regressing tumor swelling which mechanically impinges on the same surrounding tissues (24).…”

“…Hemorrhage often appears in the first days after SRS (34Y36) and may be caused by the direct thermal effect on endothelial cells, leading to the release of a variety of cytokines that may in turn trigger thrombosis and disrupt the blood-brain barrier (24). As in peritumoral hemorrhage after SRS of metastatic brain tumors, the immediate tumor swelling likely induces an increase in intravascular outflow resistance, and radiation-induced venous obliteration could promote hemorrhage (24), a complication that may be more frequent in large vascularized tumors (37). In our report, the fact that the tumor was related to NF2 and was perhaps more vessel-rich than sporadic VS could explain this side effect.…”

Hemorrhage from Arteriovenous Malformation Following Gamma Knife Radiosurgery: Pathophysiology of Rupture Early in the Latency Period

“…In the 30-day period following SRS, most reported cases of postradiosurgery hemorrhage within 72 hours of radiosurgery occurred in patients with irradiated tumors. (Franco-Vidal et al 2007;Izawa et al 2006;Park et al 2000;Suzuki et al 2003;Uchino et al 2003) There is only one report of AVM hemorrhage within 72 hours following SRS. (Nataf et al 2004) Within 4 to 30 days following SRS there are a few more documented cases of post-radiosurgery AVM hemorrhage.…”