# Refractory Radiation Necrosis After Stereotactic Radiosurgery for Cerebellar Arteriovenous Malformation: A Case Report

## TL;DR

A patient developed severe radiation necrosis after brain radiosurgery, requiring surgery when steroids failed to control symptoms.

## Contribution

This case report highlights the rare but challenging management of refractory cerebellar radiation necrosis after radiosurgery.

## Key findings

- Radiation necrosis occurred 2.5 years after stereotactic radiosurgery for a cerebellar arteriovenous malformation.
- Surgical resection was necessary when corticosteroids failed to control progressive brainstem edema.
- Postoperative recovery showed significant clinical improvement and resolution of edema.

## Abstract

Radiation necrosis is a recognized late complication of stereotactic radiosurgery for brain arteriovenous malformations, though it occurs rarely in the cerebellum. While radiation necrosis is typically managed conservatively with corticosteroids, refractory cases may require surgical intervention. A 70-year-old man underwent stereotactic radiosurgery for an incidentally detected left cerebellar arteriovenous malformation. Although complete obliteration was confirmed by digital subtraction angiography 1.5 years after stereotactic radiosurgery, he developed progressive radiation necrosis 2.5 years post-treatment, presenting with dizziness, vomiting, dysarthria, and ataxia. Initial transoral corticosteroid therapy provided symptomatic relief. Seven months later, his symptoms worsened again, and magnetic resonance imaging revealed progressive brainstem edema. Dose escalation of corticosteroids was ineffective, necessitating surgical resection. Histopathology confirmed coagulative necrosis, with remnants of the arteriovenous malformation nidus remaining. Postoperatively, the patient showed significant clinical improvement, with resolution of edema and tapering of steroids. This case highlights the challenges in managing radiation necrosis following stereotactic radiosurgery for cerebellar arteriovenous malformations. While medical therapy remains first-line, surgical resection should be considered in refractory cases to prevent complications associated with prolonged steroid use. Early recognition and intervention are crucial for optimizing patient outcomes.