Fatal tumoral hemorrhage after stereotactic radiosurgery for metastatic brain tumors: report of three cases and review of literature

Acute tumor hemorrhage occurring during stereotactic radiosurgery (SRS) for a metastatic lesion, or in the immediate post-treatment period, is believed to be extremely rare. The potential risk of hemorrhage related to SRS procedures in patients with metastatic brain tumors is not yet clearly understood. This case report describes three patients suffering acute fatal tumor hemorrhage during or immediately after SRS. One patient died within 2 weeks of treatment and the other patients were severely disabled as a result of the hemorrhage. The incidence of this complication was estimated as 0.52% per patient, 0.33% per intervention and 0.08% per lesion by reviewing our research database. Metastases from renal cell carcinoma, evidence of pre-radiosurgical peritumoral oozing of blood, anti-coagulant and anti-platelet therapy were likely to be associated with tumor hemorrhage. Although this life-threatening complication is uncommon, extra caution should be exercised when treating patients with factors that could predispose to tumoral hemorrhage.