Resection of brain radionecrosis after stereotactic radiosurgery or radiotherapy: a meta-analysis

Brain radionecrosis, a late-stage adverse effect of radiotherapy, presents diagnostic and treatment challenges. Although reports on its surgical resection have increased, no systematic review has thoroughly evaluated its clinical outcomes. To assess post-operative neurological improvement, overall survival, and complications following resection of brain radionecrosis. A search of PubMed, Embase, and the Cochrane Library was conducted following PRISMA principles (inception–February 2025). DerSimonian and Laird random-effects models were used to estimate pooled incidence with 95% confidence intervals (CIs). Eight retrospective case series involving 443 patients, predominantly with high-grade gliomas and brain metastases, met the inclusion criteria. Neurological improvement was observed in 80.7% of patients (95%CI, 66.8%–89.6%). Survival outcomes were reported heterogeneously across studies. Only two studies provided overall survival (OS) from the time of resection in histopathology-confirmed pure radionecrosis cohorts; in these, pooled 12-month and 24-month OS were 84.6% (95%CI, 65.4%–94.1%) and 73.1% (95%CI, 53.3%–86.6%), respectively. The pooled incidence of postoperative complications was 21.4% (95%CI, 11.7%–35.9%), with most complications being transient and non-life-threatening, indicating an overall favorable safety profile. Surgical resection for brain radionecrosis appeared to provide meaningful clinical benefit, with high rates of neurological improvement and an acceptable incidence of postoperative complications. Although survival outcomes were reported inconsistently and with varying time origins, available data suggest that selected patients may experience favorable short-term survival following surgery. Standardized definitions of radionecrosis and uniform reporting of survival from the time of resection are needed to strengthen the evidence base and guide clinical decision-making.