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Symptomatic radionecrosis after postoperative but not preoperative stereotactic radiosurgery in a single patient: illustrative case. J Neurosurg Case Lessons 2023 Oct 16;6(16)



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Pubmed Central ID




Scopus ID

2-s2.0-85174582314 (requires institutional sign-in at Scopus site)


BACKGROUND: Standard of care for brain metastases involves stereotactic radiosurgery (SRS). For cases that also require surgery because of lesion size, edema, or neurological symptoms, whether to provide pre- or postoperative SRS has become a prevalent debate.

OBSERVATIONS: Herein, the unique case of a patient with brain metastases of the same pathology and similar size in two different brain locations at two different times is described. The patient underwent surgery with preoperative SRS for the first lesion and surgery with postoperative SRS for the second lesion. Although both treatments resulted in successful local control, the location that received postoperative SRS developed symptomatic and rapidly progressive radiation necrosis (RN) requiring a third craniotomy.

LESSONS: Large randomized controlled trials are ongoing to compare pre- versus postoperative SRS for the treatment of symptomatic brain metastases (e.g., study NRG-BN012). Recent interest in preoperative SRS has emerged from its theoretical potential to decrease rates of postoperative RN and leptomeningeal disease. This valuable case in which both therapies were applied in a single patient with a single pathology and similar lesions provides evidence supportive of preoperative SRS.

Author List

Laurin BJ, Straza M, Noid G, Connelly JM, Mueller WM, Bovi J, Krucoff MO


Jennifer M. Connelly MD Professor in the Neurology department at Medical College of Wisconsin
Max O. Krucoff MD Assistant Professor in the Neurosurgery department at Medical College of Wisconsin
Wade M. Mueller MD Professor in the Neurosurgery department at Medical College of Wisconsin
Michael W. Straza MD, PhD Assistant Professor in the Radiation Oncology department at Medical College of Wisconsin