Early-onset symptomatic radiation necrosis after stereotactic radiosurgery in the setting of COVID-19 infection

In this brief report, we describe the case of a previously healthy 51-year gentleman who was treated with stereotactic radiosurgery to a dose of 12 Gy to a small right-sided vestibular schwannoma. MRI of the brain performed after treatment revealed stable treated disease but subsequently, the patient developed symptomatic COVID-19 based on PCR along with multiple cranial neurologic deficits, including right facial paralysis, hemifacial anesthesia, and anesthesia of the ipsilateral hard palate and tongue. MRI of the brain was repeated and demonstrated radiation necrosis in the adjacent brainstem for which he was treated with Pentoxifylline and Vitamin E, dexamethasone, and Bevacizumab with only partial improvement. The dose-volume metrics of the brainstem from his radiotherapy plan as well as the trajectory of his imaging findings do not match this clinical picture from radiotherapy alone. We review the basic pathogenesis of the inflammatory response to infection from the SARS-CoV-2 virus as well as the pathogenesis of radiation necrosis. Heightened awareness about potential risks with high-dose radiotherapy in patients with symptomatic COVID-19 should be considered.