Formation and Rupture of the Internal Carotid Artery Aneurysm after Multiple Courses of Intensity-Modulated Radiation Therapy for Management of the Skull Base Ewing Sarcoma/PNET: Case Report

Abstract

Background Aneurysm formation after stereotactic irradiation of skull base tumors is rare. The formation and rupture of an internal carotid artery (ICA) aneurysm in a patient with skull base Ewing sarcoma/primitive neuroectodermal tumor (PNET), who underwent surgery followed by multiple courses of intensity-modulated radiation therapy (IMRT) and chemotherapy, is described.

Case Description A 25-year-old man presented with a sinonasal tumor with intraorbital and intracranial growth. At that time cerebral angiography did not reveal any vascular abnormalities. The lesion was resected subtotally. Histopathologic diagnosis was Ewing sarcoma/PNET. The patient underwent multiple courses of chemotherapy and three courses of IMRT at 3, 28, and 42 months after initial surgery. The total biologically effective dose delivered to the right ICA was 220.2 Gy. Seven months after the third IMRT, the patient experienced profound nasal bleeding that resulted in hypovolemic shock. Angiography revealed a ruptured right C4–C5 aneurysm and irregular stenotic changes of the ICA. Lifesaving endovascular trapping of the right ICA was done. The patient recovered well after surgery but died due to tumor recurrence 6 months later.

Conclusion Excessive irradiation of the ICA may occasionally result in aneurysm formation, which should be borne in mind during stereotactic irradiation of malignant skull base tumors.

Keywords

malignant skull base tumor - Ewing sarcoma/PNET - intensity-modulated radiation therapy - complication - aneurysm formation - radiation-induced aneurysm

Note

This case report was presented during the 19th Annual Meeting of the Japanese Society for Stereotactic Radiosurgery (July 30, 2010; Otsu, Japan) and 10th Biennial Congress of the International Stereotactic Radiosurgery Society (May 8–12, 2011; Paris, France).

• References

• 1 Benson PJ, Sung JH. Cerebral aneurysms following radiotherapy for medulloblastoma. J Neurosurg 1989; 70 (4) 545-550
• 2 Yucesoy K, Feiz-Erfan I, Spetzler RF, Han PP, Coons S. Anterior communicating artery aneurysm following radiation therapy for optic glioma: report of a case and review of the literature. Skull Base 2004; 14 (3) 169-173
• 3 Takao T, Fukuda M, Kawaguchi T , et al. Ruptured intracranial aneurysm following gamma knife surgery for acoustic neuroma. Acta Neurochir (Wien) 2006; 148 (12) 1317-1318 ; discussion 1318
• 4 Yamaguchi S, Kato T, Takeda M, Ikeda H, Kitamura K. Ruptured distal anterior inferior cerebellar artery aneurysm following stereotactic irradiation for vestibular schwannoma: case report. Neurol Med Chir (Tokyo) 2009; 49 (5) 202-205
• 5 Gross BA, Ropper AE, Du R. Vascular complications of stereotactic radiosurgery for arteriovenous malformations. Clin Neurol Neurosurg 2013; 115 (6) 713-717
• 6 Cheng KM, Chan CM, Cheung YL, Chiu HM, Tang KW, Law CK. Endovascular treatment of radiation-induced petrous internal carotid artery aneurysm presenting with acute haemorrhage. A report of two cases. Acta Neurochir (Wien) 2001; 143 (4) 351-355 ; discussion 355–356
• 7 Auyeung KM, Lui WM, Chow LC, Chan FL. Massive epistaxis related to petrous carotid artery pseudoaneurysm after radiation therapy: emergency treatment with covered stent in two cases. AJNR Am J Neuroradiol 2003; 24 (7) 1449-1452
• 8 Lau WY, Chow CK. Radiation-induced petrous internal carotid artery aneurysm. Ann Otol Rhinol Laryngol 2005; 114 (12) 939-940
• 9 Cheng KY, Lee KW, Chiang FY, Ho KY, Kuo WR. Rupture of radiation-induced internal carotid artery pseudoaneurysm in a patient with nasopharyngeal carcinoma—spontaneous occlusion of carotid artery due to long-term embolizing performance. Head Neck 2008; 30 (8) 1132-1135
• 10 Endo H, Fujimura M, Inoue T , et al. Simultaneous occurrence of subarachnoid hemorrhage and epistaxis due to ruptured petrous internal carotid artery aneurysm: association with transsphenoidal surgery and radiation therapy: case report. Neurol Med Chir (Tokyo) 2011; 51 (3) 226-229
• 11 Tamura M, Kogo K, Masuo O , et al. The ruptured carotid artery pseudoaneurysm presenting as intractable epistaxis after repeated SRT for skull base Ewing PNET: case report. [in Japanese]. Stereotactic Radiotherapy 2011; 15: 35-44
• 12 Kushner BH, Meyers PA, Gerald WL , et al. Very-high-dose short-term chemotherapy for poor-risk peripheral primitive neuroectodermal tumors, including Ewing's sarcoma, in children and young adults. J Clin Oncol 1995; 13 (11) 2796-2804
• 13 Grier HE, Krailo MD, Tarbell NJ , et al. Addition of ifosfamide and etoposide to standard chemotherapy for Ewing's sarcoma and primitive neuroectodermal tumor of bone. N Engl J Med 2003; 348 (8) 694-701
• 14 Hotte SJ, Smith AM, Bramwell VH, Howson-Jan K. High-dose chemotherapy followed by peripheral and/or bone marrow stem cell transplant in patients with advanced sarcoma: experience of a Canadian centre. Sarcoma 2004; 8 (2–3) 63-69
• 15 Miser JS, Krailo MD, Tarbell NJ , et al. Treatment of metastatic Ewing's sarcoma or primitive neuroectodermal tumor of bone: evaluation of combination ifosfamide and etoposide—a Children's Cancer Group and Pediatric Oncology Group study. J Clin Oncol 2004; 22 (14) 2873-2876
• 16 Wilkins RM, Pritchard DJ, Burgert Jr EO, Unni KK. Ewing's sarcoma of bone. Experience with 140 patients. Cancer 1986; 58 (11) 2551-2555
• 17 Elomaa I, Blomqvist CP, Saeter G , et al. Five-year results in Ewing's sarcoma. The Scandinavian Sarcoma Group experience with the SSG IX protocol. Eur J Cancer 2000; 36 (7) 875-880
• 18 van Doorninck JA, Ji L, Schaub B , et al. Current treatment protocols have eliminated the prognostic advantage of type 1 fusions in Ewing sarcoma: a report from the Children's Oncology Group. J Clin Oncol 2010; 28 (12) 1989-1994
• 19 Louis DN, Ohgaki H, Wiestler OD , et al. The 2007 WHO classification of tumours of the central nervous system. Acta Neuropathol 2007; 114 (2) 97-109
• 20 Koenigsberg RA, Grandinetti LM, Freeman LP, McCormick D, Tsai F. Endovascular repair of radiation-induced bilateral common carotid artery stenosis and pseudoaneurysms: a case report. Surg Neurol 2001; 55 (6) 347-352
• 21 Dario A, Dorizzi A, Scamoni C, Cerati M, Balcone Grimaldi G. Iatrogenic intracranial aneurysm. Case report and review of the literature. J Neurosurg Sci 1997; 41 (2) 195-202
• 22 Grigorian A, Rajaraman V, Hunt CD. Traumatic intracranial aneurysms complicating anterior skull base surgery. J Craniomaxillofac Trauma 1998; 4 (4) 10-14
• 23 Ciceri EFM, Regna-Gladin C, Erbetta A , et al. Iatrogenic intracranial pseudoaneurysms: neuroradiological and therapeutical considerations, including endovascular options. Neurol Sci 2006; 27 (5) 317-322
• 24 Mathews SS, Kumar RM, Rupa V. Iatrogenic pseudoaneurysm: a rare complication of sinonasal surgery. Am J Otolaryngol 2011; 32 (6) 607-610
• 25 Chen Z, Zhang J, Miao H, Niu Y, Feng H, Zhu G. Delayed rupture of iatrogenic cerebral pseudoaneurysms after neurosurgical procedures: report of two cases. Clin Neurol Neurosurg 2013; 115 (8) 1552-1554