Risk And Outcome Of Intratumoral Hemorrhages After Radiosurgery

Keywords: hemorrhage, brain tumor, gamma knife, outcome, complications

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       Intratumoral hemorrhages during or after radiosurgery have previously been reported. These can result in mild to severe neurological deterioration and can even be fatal.
     We evaluated 1444 Gamma Knife® radiosurgery (GKRS) treatments of brain metastases with regard to overall risk, timing of intratumoral hemorrhage and outcome after the hemorrhage.
     Between June 2002 and September 2009, we performed 1444 (GKRS) treatments of 3850 brain metastases in 1081 patients.
     GKRS planning was based upon high resolution stereotactic MR imaging. A marginal dose of 18 to 25 Gy was prescribed. All patients had 3-monthly follow-up as long as it was considered to be clinically meaningful. All patients with a history of an intratumoral hemorrhage during or after the radiosurgery were selected for analysis.
     There were 46 intratumoral hemorrhages in 43 patients observed within 0 to 726 days after radiosurgery representing an overall risk of 3,2 % after treatment and an incidence of 1,2% among the 3850 BM that were treated. Nine (19,6%) of the hemorrhages occurred during the first week after GKRS of which 4 on the day of treatment. Sixteen (35%) and 31 (67%) of the hemorrhages occurred within the first month and within the first 3 months, respectively. The primary tumors in the 43 patients were non-small cell lung cancer (14), melanoma (10), renal cell cancer (8), breast cancer (7), gastrointestinal cancer (2), sarcoma (1) and carcinoid of the lung (1). The hemorrhage was fatal in 15 patients (32,6%) after 0 to 34 days. Seven patients died (sub)acutely. We could not find a significant relation between the tumor volume and the incidence of hemorrhage after GKRS.
     This is a retrospective study.
     The incidence of intratumoral hemorrhages after GKRS was 1,2% among the BM that were treated and occurred in 19% within the first week after treatment. It was associated with a high mortality.
     Considering the incidence and severe consequences of these hemorrhagic events these findings should be taken into account in the informed consent procedure.


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