On your treatment day please have a seat in the waiting room by the glass elevators on level 2B. A nurse or radiation therapist will meet with you and prepare you for the procedure.

How should I prepare for my treatment?

Bring these items with you to the hospital:

• Health card (OHIP).
• Medications you need to take during the day in their original containers and a list of all the medications you are taking.
• A family member or adult friend to stay with you at the hospital during your treatment and drive you home after your treatment.
• Something to eat.
• Something to read or do to help pass the time.
  Remember: You can’t wear eye glasses while the frame is on.

On the day of your treatment:

• Do not wear make-up.
• Take your usual morning medicine.
• Plan to spend most of the day at the hospital.
• The preparation and treatment times are different for each patient.
  Please note: You will be cared for in our Radiation Nursing Clinic.

If you need a wheelchair and use a lift at home:

• Come to the hospital wearing your pyjamas.
• Leave the lift sling underneath you for easy transfers.

What is stereotactic radiosurgery?

The gamma knife uses very precise beams of radiation to treat the tumours in your brain. The goal of the treatment is to stop the tumour from growing. Because the beams only focus on the tumour, there is a lower chance of nearby brain tissue being affected.

There are 5 steps to radiosurgery.

1. MRI scan
2. Putting on the frame
3. CT scan
4. Planning the treatment
5. Treatment

1. MRI scan

The MRI is done before your radiosurgery day. A dye is put into your veins during the scan to help the oncologist and neurosurgeons see the tumour or tumours in your brain. You will need to complete a questionnaire before the scan. The MRI images will be used to plan your treatment.

For the MRI, please tell us:

• If you have any devices in your body
• If you have ever worked with metal products
• If you may have any metal objects in your body
• If you are allergic to the MRI dye

2. Putting on the head frame

The stereotactic head frame is an important part of radiosurgery. The frame helps us find the exact spot of the tumour in your brain. The frame stays on your head the whole time. We use it to keep you still during the scans and treatment.

The morning of your treatment:

• A neurosurgeon and radiation therapist will attach the light frame to your head using posts and pins.
• You will be given local anesthetic (freezing medicine) to numb the skin. This may sting for about 30 seconds.
• You may feel pressure as the pins are tightened. This usually lasts 5 to 10 minutes.

3. CT scan

After your frame is in place, we will take images of your brain and skull using a CT scanner. We will take you to the imaging area by wheelchair. We will put a transparent box over your head to help us take measurements when planning your treatment. After we take all the images, we will take the box off and you will go back to the Radiation Nursing Clinic to rest.

4. Planning your treatment

To create your treatment plan we use the images from both your MRI and CT scans. Your health care team will decide:

• which area to treat
• how much radiation to give
• how they will use the radiation to treat the tumour

The treatment planning step can take 1 or more hours depending on the size and shape of the area you need to have treated.

While we are planning your treatment, you:

• will stay in the Radiation Nursing Clinic
• can eat, drink and rest
• can use the washroom
• may not walk around the clinic alone

5. What can I expect during my treatment?

When your treatment plan is ready, the team checks to make sure it is correct and safe. Then we will take you to the Unit for your treatment.

During treatment, you will not feel anything.

• The treatment step can take several hours to complete. Be prepared for at least 1 hour of treatment and sometimes up to 3 or more hours.
• The Radiation Therapists will be there at all times. They will help you get settled in the machine and make you comfortable.
• The Radiation Therapists will leave the treatment room while you receive your treatment.
• There is a microphone near your head to talk to us if you need to. There are also 3 cameras in the room so we can see you at all times.
• During your treatment, the bed will automatically move you into the next position. You can listen to music during the treatment and you can bring your own music.

What can I expect after my treatment?

After your treatment, you will go back to the Radiation Nursing Clinic.

The Radiation Oncologist will remove your head frame.

• We will watch you for 1 hour after we remove your head frame. Then you may go home.
• We will put bandages on the pin sites on your forehead. Try to keep the pin areas dry for the next 24 hours.
• You may have some bleeding or oozing in the areas where the pins were.
• You may get a headache.
• When you go home, you can go back to doing your usual activities.

How to manage possible side effects

Each patient may have different side effects. Your doctor or radiation therapist will explain the short and long term side effects of radiosurgery and how to manage them. See the following table for the most common side effects and how to manage them.

Fatigue

• Feeling tired is normal after radiation therapy.
• The day of your treatment will be a long day and can make you very tired.

What you can do:

• Try not to do too many activities and rest when you need to.
• Eat healthy foods and drink plenty of fluids.
• Read the pamphlet ‟How to Manage Your Fatigue”.

Headaches

• Some patients get headaches from wearing the frame.

What you can do:

• You can take Tylenol or Advil or a prescription for pain medicine from your doctor when you need to.

Swelling

• You may notice swelling around your eyes. The local anesthetic can cause this.

What you can do:

• You can apply an ice pack to your eyes to help with the swelling.

Bleeding or fluid leaking from the pin areas

• Some blood or fluid may leak from the pin areas for 2 or 3 days after treatment.

What you can do:

• Leaking from the pins is normal. If there’s bleeding, press down on the site with gauze for 5 minutes. It should stop.
• If there’s leaking at the pin sites, clean the area with alcohol and cover with a Band-Aid.

Hair loss

• Some patients lose hair in a small area of the scalp. This is not common.

What you can do:

• You can expect your hair to grow back within the next few months.

Nausea and vomiting

• You may have nausea (feeling like you need to throw up) and vomiting (throwing up), but this is not common.

What you can do:

• Tell your health care provider if you have an upset stomach.
• You can take medicine to help with nausea and vomiting.

Swelling in the brain

Weeks or months after radiosurgery you may have swelling in your brain. This may cause headaches, nausea and vomiting.

To help with some of the symptoms, we often prescribe a medicine called Decadron.

How to take Decadron

• Take it after meals or with a snack to avoid feeling nauseated or getting an upset stomach.
• Take your dose in the morning and at lunch because Decadron can disturb your sleep.
• Let your doctor know if you have diabetes or if diabetes runs in your family. Decadron may change your blood sugar levels.

For the next 4 weeks, your doctor recommends that you take Decadron. Please follow the doctor's recommended schedule.

If your symptoms get worse as you take less Decadron, please call the Brain Metastases Clinic and we will talk with you about trying another schedule.

Some other possible side effects of Decadron may include:

• heartburn or indigestion
• sore mouth
• yeast infections
• swelling of face, hands, upper back and neck area
• weakness in the legs that makes it hard to walk up stairs or get out of a chair
• irritability (getting easily upset) or other changes in mood
• increased appetite
• trouble sleeping or restlessness (unable to relax)
• skin rash

Questions and concerns

Watch videos about frame and mask-based treatments on the UHN Brain Metastases Clinic webpage.

Please call us if you have any questions or concerns:

Princess Margaret Cancer Centre
Phone: 416 946 4501 extension 6325
Monday to Friday 8:30 am to 4:30 pm

Evenings, weekends and holidays, you can call either the Neurosurgeon or Radiation Oncologist:

• Neurosurgeon on-call
  Phone: 416 340 3155 (Ask for the neurosurgeon on-call)
• Radiation Oncologist on-call
  Phone: 416 946 2000 (Ask for the radiation oncologist on-call)

What follow-up care do I need?

Before you leave, we will give you an appointment to the Brain Metastases Clinic. Your follow-up will include another MRI. We can use Telehealth if it is hard for you to come back to Toronto.

The Brain Metastases Clinic treats and manages brain metastases. You should see your family doctor or main oncologist for any other problems.