Bevacizumab withdrawal–associated cortical hyperperfusion in recurrent high-grade astrocytoma: An underrecognized MRI pitfall

Bevacizumab is widely used in recurrent high-grade gliomas due to its anti-angiogenic effects mediated through vascular endothelial growth factor (VEGF) inhibition. While radiological pseudo response during treatment is well recognized, cerebral hemodynamic alterations following treatment discontinuation are poorly characterized. We report a 50-year-old male with recurrent IDH-mutant WHO grade 4 astrocytoma who developed focal cortical hyperperfusion on perfusion MRI after cessation of long-term Bevacizumab therapy. The finding occurred in the absence of diffusion restriction, seizure activity, systemic hypertension, stroke episode or imaging evidence of tumor recurrence. The imaging pattern is most consistent with a transient vascular autoregulatory rebound phenomenon related to vascular endothelial growth factor pathway re-equilibration after anti-angiogenic withdrawal.