Radiation necrosis following gamma knife surgery: a case-controlled comparison of treatment parameters and long-term clinical follow up

Object. Radiation necrosis is the only significant complication of gamma knife surgery (GKS). The authors studied treatment plan parameters in patients who had radiation necrosis to determine if risk factors for necrosis could be identified. Methods. Between September 1994 and December 1998, 286 patients were treated with GKS by the senior author. Of the 243 patients who were suitable for analysis, 17 developed radiation necrosis and were prospectively followed. Concurrently, 17 patients without necrosis were randomly selected as case controls on the basis of histological findings in their lesions. Integral dose-volume histograms (DVHs) were calculated and dose-volume treatment parameters were determined. A comparison was made with both the established Kjellberg and Flickinger isonecrosis risk lines. Clinical outcome was assessed according to time to resolution of symptoms and return to normal radiographic appearance. Conclusions. Treatment plan variables associated with the risk of necrosis were increased tumor volume (TV) integral dose, increased TV, and increased 10-Gy volume. Other risk factors included repeated radiosurgery to the same lesion and glioma histological findings. The Kjellberg 1% risk line predicted a 5% risk of radiation necrosis and the Flickinger 3% risk line predicted a 3% risk. The median time to development of necrosis was 4 months, and symptomatic and radiographic recovery times were 7.5 and 10.5 months, respectively. The median survival time in patients with necrosis was 30 months. The authors recommend prospective TV determination and DVH calculation for all radiosurgical treatments and the avoidance of repeated radiosurgical treatments to the same lesion when possible.