J Korean Neurosurg Soc.  2024 Jul;67(4):458-466. 10.3340/jkns.2023.0203.

A Potential Risk of Radiation-Induced Cavernous Malformations Following Adjuvant Gamma Knife Radiosurgery for Mesial Temporal Lobe Epilepsy

• Kim J
• Byun J
• Lee DH
• Hong SH

• KMID: 2556743
• DOI: http://doi.org/10.3340/jkns.2023.0203

Abstract

Objective
: Several clinical studies have explored the feasibility and efficacy of radiosurgical treatment for mesial temporal lobe epilepsy, but the long-term safety of this treatment has not been fully characterized. This study aims to report and describe radiation-induced cavernous malformation as a delayed complication of radiosurgery in epilepsy patients.
Methods
: The series includes 20 patients with mesial temporal lobe epilepsy who underwent Gamma Knife radiosurgery (GKRS). The majority received a prescribed isodose of 24 Gy as an adjuvant treatment after anterior temporal lobectomy.
Results
: In this series, we identified radiation-induced cavernous malformation in three patients, resulting in a cumulative incidence of 18.4% (95% confidence interval, 6.3% to 47.0%) at an 8-year follow-up. These late sequelae of vascular malformation occurred between 6.9 and 7.6 years after GKRS, manifesting later than other delayed radiation-induced changes, such as radiation necrosis. Neurological symptoms attributed to intracranial hypertension were present in those three cases involving cavernous malformation. Of these, two cases, which initially exhibited an insufficient response to radiosurgery, ultimately demonstrated seizure remission following the successful microsurgical resection of the cavernous malformation.
Conclusion
: All things considered, the development of radiation-induced cavernous malformation is not uncommon in this population and should be acknowledged as a potential long-term complication. Microsurgical resection of cavernous malformation can be preferentially considered in cases where the initial seizure outcome after GKRS is unsatisfactory.

Keyword

Cerebral cavernous malformation; Gamma Knife radiosurgery; Mesial temporal lobe epilepsy; Hippocampal sclerosis; Anterior temporal lobectomy

Figure

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  Fig. 1. Delayed radiation-induced changes following GKRS for MTLE. Dotted lines indicate the 95% CIs. Early T2 hyperintense changes were evident in the follow-up MRI, conducted 1-year post-GKRS in this series. Late delayed radiation-induced changes, such as radiation necrosis and tumefactive cyst formation, were manifested in eight cases at a median of 5.3 years (IQR, 4.5–6.7). RICMs developed in a subsequent period, resulting in a cumulative incidence of 18.4% (95% CI, 6.3% to 47.0%) at the 8-year time point. GKRS : Gamma Knife radiosurgery, MTLE : mesial temporal lobe epilepsy, CI : confidence interval, MRI : magnetic resonance imaging, RICM : radiation-induced cavernous malformations, IQR : interquartile range.

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  Fig. 2. Cases presenting RICM after adjuvant GKRS for MTLE. Shown are axial sections from post-contrast T1-weighted MRIs for case #1 (A-C), case #2 (E-G), and case #3 (I-K). An axial section of a T2-weighted gradient recalled echo image supports the radiological diagnosis of cavernous malformation (indicated by arrowheads) for case #3 (L). Histopathological findings for case #1 (D) and case #2 (H) are shown using Hematoxylin-Eosin staining (scale bar=100 μm). RICM : radiation-induced cavernous malformations, GKRS : Gamma Knife radiosurgery, MTLE : mesial temporal lobe epilepsy, MRI : magnetic resonance imaging.

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Reference

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