Article
Malignant brain edema after radiosurgery of a large vestibular schwannoma – case report
Ausgeprägtes Hirnödem nach Gammaknifebestrahlung eines großen Akustikusneurinoms
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Authors
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S. Kliesch
- Klinik für Neurochirurgie, Universitätsklinikum Greifswald
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H. W. S. Schroeder
- Klinik für Neurochirurgie, Universitätsklinikum Greifswald
| Published: | May 30, 2008 |
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Outline
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Objective: To present a case of a life threatening brain edema after gamma-knife radiosurgery of a large vestibular schwannoma.
Methods: A 62-year-old female presented with headache, progressing ataxia, standing distortion and right sided hearing loss. MRI revealed a large vestibular schwannoma. Initially, she was treated by partial microsurgical resection of the tumor. 4 months after surgery, she underwent stereotactic gammaknife radiation with an applied marginal dose of 13 Gy. With a latency of several months she showed progressive neurological deterioration. Because of ventricular enlargement a vp-shunt was implanted. 3 months later she was rehospitalized because of progressive weakness, facial palsy, and decrease of consciousness. MRI revealed enlargement of the tumor and progressive perifocal brain edema extending into the right cerebellum, brainstem, midbrain, thalamus and posterior portion of capsula interna. She was in a comatose state when she had been admitted to our institution for reoperation. The tumor was nearly totally removed via a retromastoid approach. A small remnant of the tumor capsule which was very adherent to the brain stem had to be left in place to avoid brainstem injury. 2 weaks after the surgery, the brain edema resolved and the patient became awake. Now, 2 years after surgery, she is without tumor recurrence. Because of the cerebellar resection which was necessary to approach the tumor, she complains of balance problems.
Conclusions: Although radiosurgery seems to be a safe treatment option in small vestibular schwannomas, radiation of large tumors is less effective. The etiology of the described malignant brain edema remains unclear. May be a radiation-induced impairment of the blood-brain barrier together with the tumor-related compression of the brain tissue was the cause. Surprisingly rapid was the improvement of the edema and the state of the patient after surgical intervention. We should be aware that stereotactic radiation of large vestibular schwannomas might result in a life-threatening edema which requires early surgical intervention.
