Yonsei Med J.  2015 Nov;56(6):1714-1720. 10.3349/ymj.2015.56.6.1714.

Pathological Evaluation of Radiation-Induced Vascular Lesions of the Brain: Distinct from De Novo Cavernous Hemangioma

• Cha YJ
• Nahm JH
• Ko JE
• Shin HJ
• Chang JH
• Cho NH
• Kim SH

• KMID: 2345904
• DOI: http://doi.org/10.3349/ymj.2015.56.6.1714

Abstract

PURPOSE
We aimed to evaluate the histologic and radiologic findings of vascular lesions after stereotactic radiosurgery (SRS) categorized as radiation-induced cavernous hemangioma (RICH).
MATERIALS AND METHODS
Among 89 patients who underwent neurosurgery for cavernous hemangioma, eight RICHs from 7 patients and 10 de novo CHs from 10 patients were selected for histopathological and radiological comparison.
RESULTS
Histologically, RICHs showed hematoma-like gross appearance. Microscopically, RICH exhibited a hematoma-like area accompanied by proliferation of thin-walled vasculature with fibrin deposits and infiltrating foamy macrophages. In contrast, CHs demonstrated localized malformed vasculature containing fresh and old clotted blood on gross examination. Typically, CHs consisted of thick, ectatic hyalinized vessels lined by endothelium under a light microscope. Magnetic resonance imaging of RICHs revealed some overlapping but distinct features with CHs, including enhancing cystic and solid components with absence or incomplete popcorn-like appearance and partial hemosiderin rims.
CONCLUSION
Together with histologic and radiologic findings, RICH may result from blood-filled space after tissue destruction by SRS, accompanied with radiation-induced reactive changes rather than vascular malformation. Thus, the term "RICH" would be inappropriate, because it is more likely to be an inactive organizing hematoma rather than proliferation of malformed vasculature.

Keyword

Brain; hemangioma; cavernous; central nervous system; radiosurgery

MeSH Terms

Adult
Aged
Brain/*pathology
Brain Neoplasms/*pathology
Female
Hemangioma, Cavernous/complications/*pathology/surgery
Hematoma/surgery
Humans
*Magnetic Resonance Imaging
Male
Middle Aged
Radiosurgery/adverse effects
Treatment Outcome

Figure

• 

  Fig. 1 Gross and microscopic findings of radiation-induced cavernous hemangioma (RICH) following stereotactic radiosurgery and de novo cavernous hemangioma (CH). RICH shows a hematoma-like cut surface without grossly identifiable vascular structure (A), while cut surfaces of de novo CH show clustered variable sized vessels containing fresh and old hemorrhage, surrounded by hemosiderin-tinged brain parenchyma (B). Microscopically, RICH shows hematoma like-area without recognizable vasculature (C), whereas CH consists of clusters of vascular lumens lined by endothelial cells (D). With α-SMA immunohistochemical staining, well-formed vasculature is not discernable in RICH (E), whereas endothelial lined lumens in CH are well-delineated (F).

• 

  Fig. 2 Radiation-induced cavernous hemangioma (RICH) shows thin-walled vessels with fibrin and infiltrating foamy macrophages in the vessel walls (A). On the contrary, cavernous hemangioma (CH) consists of thick walled ectatic vessels sharing a common wall (B). This difference is further highlighted by trichrome staining, in which RICH lacks hyalinization in vessel walls (C) and CH shows prominent hyalinization (D). CD68 staining underscores the collection of foamy macrophages splitting the vessel walls in RICH (E). In CH, only a few macrophages are scattered in areas of old hemorrhage (F).

• 

  Fig. 3 (A-D) Radiological comparison of radiation-induced cavernous hemangioma (RICH) and de novo cavernous hemangioma (CH). Although a popcorn-like appearance and partial hemosiderin rim in RICH overlap with CH, other atypical findings such as an unilocular cystic area with some solid component and prominent perilesional edema are distinguishing features of RICH. (E, F, and G) A popcorn-like appearance, complete hemosiderin rim, and less prominent perilesional edema are common findings of de novo CH.

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