Symptomatic Post-Radiosurgery Intratumoral Hemorrhage in a Case of Vestibular Schwannoma: A Case Report and Review of the Literature

Abstract

Gamma knife radiosurgery (GKRS) is considered an established treatment for vestibular schwannoma (VS) in selected patients. Spontaneous intratumoral hemorrhage in VS after GKRS is very rare. In this report, we present a 63-year-old gentleman who had right-side severe sensorineural hearing loss on MRI showing a right cerebellopontine angle tumor (volume 4.96 cm<sup>3</sup>) with an internal acoustic meatus extension. He underwent GKRS with the prescription dose of 12 Gy to the 50% isodose line, covering 4.66 cm<sup>3</sup> (i.e., 94%) of the tumor. Ten days later, he experienced a symptomatic intra­lesional hemorrhage with a mass effect over the brainstem. When symptoms did not resolve after an initial conservative approach, he underwent surgical decompression of the lesion. Postoperatively, the patient had facial palsy but was free of disabling vertigo and ataxia. At the 6-month follow-up, he was doing well without any other complaints. Although rare, an intralesional bleed can occur after GKRS in VS and should be suspected when new severe symptoms develop immediately after therapy.

Intratumoral hemorrhage in jugular foramen schwannoma after stereotactic radiosurgery: A case report

“…[ 15 ] Regarding VS, about 50 cases have been reported in the literature. [ 15 , 31 ] Carlson et al . estimated that the rate of intratumoral hemorrhage in untreated VS was 0.4%, which decreased to only 0.2% after excluding patients on anticoagulation.…”

“…In particular, limited to clinically significant hemorrhage, there are eight reported cases in literature [ Table 1 ]. [ 5 , 9 , 11 , 13 , 16 , 20 , 31 ] A few patients developed symptomatic hemorrhage within 1 month after SRS, while others developed it several months or years later. Some mechanisms could be assumed from previous studies.…”

Intratumoral Hemorrhage in Jugular Foramen Schwannoma after Stereotactic Radiosurgery: A Case Report

“…27 Regarding vestibular schwannoma, about 50 cases have been reported in literature. 27,28 Carlson et al estimated that the rate of intratumoral hemorrhage in untreated vestibular schwannoma was 0.4%, which decreased to only 0.2% after excluding patients on anticoagulation. 19 The symptoms are headache, nausea and vomiting, cranial neuropathy, ataxia and so on.…”

“…In particular, limited to clinical signi cant hemorrhage, there are eight reported case in literature (Table 1). 22,[28][29][30][31][32][33] Some mechanism could be assumed from previous studies. First, radiation induces microhemorrhage as well as other estimated factors, leading to necrotic expansion and rarely massive hemorrhage.…”

“…The previously reported post-SRS cases were managed surgically in six cases and conservatively in two other cases, largely ending up in a good recovery (Table 1). 22,[28][29][30][31][32][33]…”