Acute and chronic hemorrhage from radiation-induced cavernous malformation associated with late-delayed radiation necrosis in long surviving glioma patients: A case report

Although radiation therapy is a standard treatment strategy for patients with glioma, its delayed complications are not clearly understood. Radiation-induced cavernous malformation (RICM) is one of the complications in the delayed phase following radiation therapy, which usually occurs in children. Herein we present three cases of RICM with radiation necrosis in long surviving adult glioma patients, 2 with oligoastrocytoma and one with anaplastic ependymoma. Two of three patients had received an obvious overdose of radiation by additional stereotactic radiation therapy. Repeated episodes of either acute or chronic hemorrhages from RICM worsened the neurological symptoms in all cases. The interval between the last irradiation and the occurrence of symptoms was 45-173 months. The presence of hypointense rim on FLAIR or T2* on magnetic resonance imaging, which resembles the appearance of sporadic cavernous malformations, could be helpful in differentiating RICM from tumor recurrence. Surgical resection was effective in alleviating the symptoms. Microscopically, RICM is a vascular lesion with vulnerable vessels, which are observed in the center of the radiation necrosis. Repeated hemorrhages from these vessels cause either gradual or sudden worsening of neurological symptoms. Therefore, radiation overdose, which results in radiation injury, should be avoided in low grade glioma patients, who could potentially survive for a long period.