Elsevier

World Neurosurgery

Volume 81, Issues 3–4, March–April 2014, Pages 652.e1-652.e4
World Neurosurgery

Peer-Review Short Report
Laser-Interstitial Thermal Therapy for Refractory Cerebral Edema from Post-Radiosurgery Metastasis

https://doi.org/10.1016/j.wneu.2013.10.034Get rights and content

Background

Stereotactic radiosurgery is often an effective tool for the treatment of brain metastases. A complication of radiosurgical treatment for brain metastasis can be persistent cerebral edema. Treatments of this refractory cerebral edema include observation, corticosteroids, and surgical resection of the edema-inducing mass. Laser-interstitial thermal therapy is a minimally invasive technique for ablating intracranial lesions. It may provide a treatment option for metastases after radiosurgery causing refractory cerebral edema.

Case Description

We report the case of a 64-year-old man with lung adenocarcinoma presenting to our department with left hemiparesis. Brain magnetic resonance imaging showed an 18-mm enhancing lesion in the right external capsule with significant surrounding edema. The lesion was treated by radiosurgery. There was persistent edema after radiosurgery. The patient required continued corticosteroid therapy to maintain his ability to ambulate. He developed refractory hyperglycemia, weight gain, and bilateral proximal muscle weakness secondary to this therapy. Fourteen weeks after radiosurgery, he underwent laser-interstitial thermal therapy for lesion ablation. He was weaned off corticosteroids during 2 weeks and maintained his strength during the following month.

Conclusions

Laser-interstitial thermal therapy may be a treatment option for refractory cerebral edema after stereotactic radiosurgery to a metastasis. This therapy may be of particular use in deep-seated lesions refractory to corticosteroid therapy.

Introduction

Stereotactic radiosurgery is often the treatment of choice for brain metastases (5). Persistent or worsening cerebral edema can occur after radiosurgery and, in some instances, patients can develop radiation necrosis (1). Treatment of this edema includes observation, corticosteroid therapy, and surgical removal of the mass. Systemic side effects from corticosteroids and lesions that are difficult to access surgically can make the treatment of edema after radiosurgery for a metastasis difficult.

Laser-interstitial thermal therapy (LITT) delivers focal heat energy to coagulate tissue with a sharp ablation boundary zone (8). Intracranial LITT involves the stereotactic placement of a probe into a lesion followed by laser ablation while performing real-time magnetic resonance (MR) thermometry to monitor intracranial temperature. Recent studies have suggested the utility of LITT in the treatment of brain metastases and intracranial radiation necrosis 2, 8.

Persistent cerebral edema despite conventional therapies in patients with brain metastases remains a neurosurgical challenge. Current alternative therapies include bevacizumab and pentoxifylline combined with vitamin E 6, 10. LITT may be a useful treatment option for cerebral edema after stereotactic radiosurgery to a metastasis.

Section snippets

History and Physical Examination

A 64-year-old man with lung adenocarcinoma presented with left hemiparesis. He was diagnosed with stage IIIB lung adenocarcinoma 3 years prior, for which he underwent a pneumonectomy followed by chest radiotherapy and cisplatin–gemcitabine chemotherapy. The patient's past medical history was significant for hypertension, atrial fibrillation, and coronary artery disease status after coronary artery bypass grafting. On physical examination, the patient had a left hemiparesis with left proximal

Discussion

Multiple treatment options exist after stereotactic radiosurgery radiation necrosis. In patients who are asymptomatic, close monitoring with serial imaging is often sufficient. In those patients who become symptomatic from persistent edema or direct mass effect, treatment is warranted. Corticosteroids are the first line of treatment as a temporizing measure until the inflammatory reaction rescinds. If corticosteroids are insufficient or intolerable, craniotomy or bevacizumab is warranted. It is

Conclusions

LITT may be a viable, minimally invasive treatment option for refractory cerebral edema after stereotactic radiosurgery to a brain metastasis. This therapy may be of particular use for ablation of deep-seated lesions that have failed corticosteroid therapy.

Acknowledgments

The authors thank Paul H. Dressel, B.F.A., for preparation of the illustrations and Debra J. Zimmer for editorial assistance.

References (10)

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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