Case Report

Laser Interstitial Thermotherapy for Treatment of Symptomatic Peritumoral Edema After

Radiosurgery for Meningioma
Christopher S. Hong1, Jason M. Beckta2, Adam J. Kundishora1, Aladine A. Elsamadicy1, Veronica L. Chiang1,2

Key words - BACKGROUND: Symptomatic peritumoral edema (PTE) is a known compli-

- Laser interstitial thermotherapy
- Meningioma
- Neurosurgery
- Peritumoral edema
- Radiation necrosis
Abbreviations and Acronyms
FLAIR: Fluid-attenuated inversion recovery
LITT: Laser interstitial thermotherapy
MRI: Magnetic resonance imaging
PTE: Peritumoral edema
WHO: World Health Organization
From the Departments of 1Neurosurgery and 2Therapeutic
Radiology, Yale University School of Medicine, New Haven,
Connecticut, USA
To whom correspondence should be addressed:
Veronica L. Chiang, M.D.
[E-mail: veronica.chiang@yale.edu]
Citation: World Neurosurg. (2020) 136:295-300.
https://doi.org/10.1016/j.wneu.2020.01.143
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2020 Elsevier Inc. All
rights reserved.
cation after radiosurgical treatment of meningiomas. Although the edema in
most patients can be successfully managed conservatively with corticosteroid
therapy or bevacizumab, some medically refractory cases may require surgical
resection of the underlying lesion when feasible. Laser interstitial thermother-
apy (LITT) continues to gain traction as an effective therapeutic modality for the
treatment of radiation necrosis where its biggest impact is through the control of
peritumoral edema.
- CASE DESCRIPTION: A 56-year-old woman with neurofibromatosis 2 pre-
sented with a symptomatic, regrowing left frontotemporal lesion that had pre-
viously been radiated, then resected with confirmed recurrence of grade I
meningioma, and subsequently radiated again for lesion recurrence. Given her
history of 2 prior same-side craniotomies, including a complication of wound
infection, she was not a candidate for further open surgical resection. Having
failed conservative management, she underwent LITT with intraoperative biopsy
demonstrating viable grade I meningioma. Postoperatively, she demonstrated
radiographic marked, serial reduction of PTE and experienced resolution of her
symptoms.
- CONCLUSIONS: This case demonstrates that LITT may be a viable alternative
treatment for patients with meningioma with symptomatic PTE who have failed
medical therapy and require surgical intervention.

INTRODUCTION
The development of symptomatic peritu-
moral edema (PTE) causing focal neuro-
logic deficits, seizures, and intracranial
hypertension is a known complication
after radiosurgical treatment of meningi-
omas.1-3 Its pathophysiology has been
attributed to both factors related to radi-
ation type and dosing and characteristics
intrinsic to the treated meningioma.4-7
First-line therapy for symptomatic PTE
after meningioma radiation remains high-
dose corticosteroids, but alternative treat-
ments have included bevacizumab or sur-
gical resection in those with accessible
lesions. However, in cases of persistent
PTE refractory to corticosteroids and
otherwise not amenable to bevacizumab or
surgical resection, further treatment op-
tions remain limited.
Magnetic resonance imaging (MRI)e
guided laser interstitial thermotherapy
(LITT) has become an increasingly
popular minimally invasive neurosurgical
procedure for both the treatment of path-
ologic diagnoses and delivery of ablative
therapy. The most robust indication for
LITT is the treatment of symptomatic
radiation necrosis after previous radio-
surgery for brain metastases.8-11 In this
report, we present a patient, who having
exhausted medical, surgical, and radio-
therapy options, underwent successful
LITT for treatment of symptomatic PTE
related to her tumor. As such, LITT may be a
viable alternative treatment of PTE after
radiosurgical treatment of meningioma.
CASE DESCRIPTION
The index patient is a 56-year-old women
with known neurofibromatosis type 2. As
part of her extensive neurosurgical history,
she had previously undergone multiple
resections of both cranial and spinal me-
ningiomas. In particular, in the region of
interest, she had undergone initial gamma
knife radiosurgery 7 years prior to tumor
in the same location (18 Gy to the 50%
isodose line) and 3 adjacent tumors, fol-
lowed 1 year later by a large fronto-
temporal craniotomy for resection of the
regrowing and symptomatic dominant left
frontotemporal lesion and 4 other adjacent
tumors. Pathology confirmed viable World
Health Organization (WHO) grade I
psammomatous meningioma with areas
of focal necrosis in all resected specimens.
Surgery was complicated by a wound
infection resulting in the removal of the
original bone flap and subsequent
replacement with a cranioplasty. Five years
after craniotomy, given progressive tumor
regrowth in the previously surgically
resected region associated with develop-
ment of recurrent, albeit mild, right-sided
hemiparesis, she underwent repeat
gamma knife radiosurgery. A total of 15 Gy
to the 50% isodose line was delivered to
the dominant left frontotemporal lesion

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CHRISTOPHER S. HONG ET AL.
Figure 1. Gamma knife radiosurgery plan. Representative T1-weighted magnetic resonance imaging
after gadolinium administration showing (A) coronal, (B) sagittal, and (C) axial slices of 15 Gy to the
50% isodose line (inner yellow line), 8 Gy to the 25% isodose line (inner green line), and 4 Gy to the
12.5% isodose line (outer green line).
(Figure 1). Six months after this second
gamma knife treatment, she presented
with new onset aphasia and worsening
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LITT FOR EDEMA IN IRRADIATED MENINGIOMAS
right-sided hemiparesis resulting in a
fall and fracture of her right wrist.
MRI demonstrated a persistent, dominant
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2020.01.143
CASE REPORT
left frontotemporal extra-axial lesion
measuring 2.2  2.3  3.3 cm (16.7 cm3)
with significant increase in the amount of
surrounding T2 fluid-attenuated inversion
recovery (FLAIR) changes extending into
the adjacent temporal lobe (Figure 2AeD).
Her symptoms improved significantly with
steroids, but her clinical course was
complicated by development of shingles,
significant weight gain, and severe
gastrointestinal reflux. Bevacizumab was
felt to be contraindicated given her recent
fracture. Repeat surgical resection was
considered, but because of her history of
multiple same-sided craniotomies and
prior infection, LITT was proposed with the
possibility of craniotomy salvage if needed.
The patient tolerated the LITT proced-
ure without any significant events. An
alternative trajectory to her lesion avoiding
her prior craniotomies was chosen allow-
ing the laser fiber also to be introduced
along the long axis of the lesion
(Figure 3AeC). LITT was performed using
the full-fire 3.3-mm diameter laser fiber
and the NeuroBlate system (Monteris
Medical, Minneapolis, Minnesota, USA) in
accordance with our previously published
institutional experience.8,12 Complete
ablation was achieved (Figure 3D and E).
Biopsy was also performed prior to
thermocoagulation and again
demonstrating viable WHO grade I
psammomatous meningioma with a
Ki-67 index <5%.
An MRI obtained 2 weeks after treatment
demonstrated similar but slightly
decreased T2 FLAIR signal and thinner rim
enhancement compared with preoperative
imaging. Clinically, she was without motor
deficits, and her speech had returned to
baseline, in the setting of a slow steroid
taper, which was eventually successfully
weaned off by the time of her 6-week sur-
veillance MRI. At 6 weeks there was further
reduction in perilesional edema associated
with a notable decrease in the size of the
contrast-enhancing lesion (Figure 2EeH).
Scans at 3-month follow-up revealed a
further decrease in size of the ablated lesion,
and imaging at 1-year post-LITT showed res-
olution of T2 FLAIR edema and minimal
residual enhancement (Figure 4). At the last
follow-up, 3 years after LITT, the ablated
lesion remained as a small area of nodular
enhancement with no perilesional edema, and
the patient remained neurologically asymp-
tomatic from this lesion (Figure 4EeH).
 CASE REPORT
CHRISTOPHER S. HONG ET AL. LITT FOR EDEMA IN IRRADIATED MENINGIOMAS

Figure 2. Preoperative and 2-week follow-up magnetic resonance imaging fluid-attenuated inversion recovery (FLAIR). Postoperative MRI 2 weeks
(MRI) after laser interstitial thermotherapy (LITT). Preoperative MRI of the after LITT is shown on (E) axial and (F) coronal T1-weighted MRI after
ablated lesion is shown on (A) axial and (B) coronal T1-weighted MRI after gadolinium administration and (G) axial and (H) coronal T2-weighted FLAIR.
gadolinium administration and (C) axial and (D) coronal T2-weighted

DISCUSSION symptomatic. Although high-dose corti- predominantly described its use in

Meningiomas remain the most common
primary brain tumor and differ from most
intra-axial pathologies by nature of their
extra-axial location and typically benign
pathology. Although first-line treatment
remains surgical resection, which fortu-
nately is curative in most cases of gross or
near-total resection, adjuvant radiation
may be necessary for higher-grade tumors
(WHO grade II or III) or in patients with
syndromic conditions such as neurofibro-
matosis 2, multiple endocrine neoplasia 1,
Cowden syndrome, and Werner syn-
drome, who are at high risk of multifocal
tumor recurrence.13-16 Radiosurgery is
often first-line treatment of these tumors
given patient reluctance and intrinsic risks
of multiple craniotomies. Radiosurgery,
especially when repeated to the same
location, carries a risk of development of
delayed PTE that can become significantly
costeroids remain first-line therapy, in
refractory cases, few alternative medical
therapies exist. Other systemic therapies
with mixed results but potential efficacy in
meningiomas are somatostatin analogues
in somatostatin receptor-positive tu-
mors,17-19 interferon alpha,20,21 and
bevacizumab.22,23 Surgical resection is
possible in patients with accessible
lesions, but when these therapies fail
and surgery is not an option, few
alternative treatments exist.
LITT for meningiomas has also been
described in a handful of prior case series,
typically involving patients with multiple
prior craniotomies for whom further sur-
gery was deemed high risk or because of
patient preference.24-26 As this report
demonstrates, however, LITT may be a
viable surgical alternative for the treatment
of symptomatic PTE. Prior studies have
intra-axial pathologies for primary and
secondary brain tumors and radiation ne-
crosis.12,27,28 Recently, its use was
affirmed in a multicenter prospective
study for the treatment of radiosurgical
failure or complication in brain
metastases.29 Furthermore, LITT has
been shown to compare favorably with
craniotomy for the same patient
population.9
Development of symptomatic PTE is a
known complication after radiosurgery to
meningiomas, with rates ranging widely
from 5% to 46%2,3; however, larger series
have reported lower values closer to 5%e
10%.30,31 However, it is often difficult to
determine whether the main cause of
PTE is related to tumor progression or
postradiation changes, with a recent
study demonstrating that previously
radiated meningiomas with predominant

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 CASE REPORT
CHRISTOPHER S. HONG ET AL. LITT FOR EDEMA IN IRRADIATED MENINGIOMAS

Figure 3. Laser interstitial thermotherapy (LITT) trajectories and demonstrate trajectory of the catheter to administer LITT within
thermal damage threshold lines. Representative intraoperative the center of the lesion. Representative axial slices of thermal
(A) coronal, (B) sagittal, and (C) axial slices of T1-weighted damage threshold lines are shown for (D) protein denaturation in
magnetic resonance imaging after gadolinium administration yellow and (E) cell death in blue.

radiation necrosis on biopsy responded
most readily to low-dose bevacizumab
compared with samples with mostly
viable/recurrent tumor.22 In the case of our
index patient, intraoperative biopsy
demonstrated viable tumor and the
etiology of the perilesional edema
remains uncertain. The edema however
responded to LITT in a time frame
similar to radiation necrosis pathology in
that there was significant and prompt
reduction of this edema after ablative
therapy. Based on these observations, we
hypothesize that the centers of previously
radiated meningiomas may harbor viable
tumor, but these lesions may develop
symptomatic secondary radiation necrosis
pathology at the periphery of the lesion
interface with normal brain tissue which
may then be the cause of the perilesional
edema. Further studies that compare
biopsy of the center versus the periphery
of these lesions may confirm this
possibility.
CONCLUSIONS
As LITT continues to become increasingly
commonplace in the neurosurgical arma-
mentarium, the applications for this

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 CASE REPORT
CHRISTOPHER S. HONG ET AL. LITT FOR EDEMA IN IRRADIATED MENINGIOMAS

Figure 4. Longer-term follow-up surveillance magnetic resonance imaging fluid-attenuated inversion recovery (FLAIR). Postoperative MRI at 3 years
(MRI) after laser interstitial thermotherapy (LITT). Postoperative MRI at 1 after LITT is shown on (E) axial and (F) coronal T1-weighted MRI after
year after LITT is shown on (A) axial and (B) coronal T1-weighted MRI after gadolinium administration and (G) axial and (H) coronal T2-weighted FLAIR.
gadolinium administration and (C) axial and (D) coronal T2-weighted

technology will continue to expand. This
report demonstrates an additional appli-
cation for LITT to treat cases of symp-
tomatic PTE after meningioma
radiosurgery, for which medical therapies
have failed and further surgery may be
morbid.
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Conflict of interest statement: V. L. Chiang is a consultant for
Monteris Medical Inc. (Minnesota, USA) and a speaker for
BrainLab, Inc. (Munich, Germany).
Received 13 November 2019; accepted 18 January 2020
Citation: World Neurosurg. (2020) 136:295-300.
https://doi.org/10.1016/j.wneu.2020.01.143
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2020 Elsevier Inc. All
rights reserved.