{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T04:53:52Z","timestamp":1777006432455,"version":"3.51.4"},"reference-count":55,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,4,14]],"date-time":"2026-04-14T00:00:00Z","timestamp":1776124800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Background: Radiotherapy is essential for skull base tumor management but carries the risk of radiation-induced brain injury (RIBI). This spectrum ranges from transient radiation-induced contrast enhancement (RICE) to irreversible necrosis. Distinguishing these entities from tumor progression is critical, particularly with the increasing adoption of proton therapy. Methods: A comprehensive narrative review of the peer-reviewed literature was conducted up to October 1, 2025. The search strategy focused on adult patients treated for skull base malignancies, synthesizing data on dose\u2013volume metrics, incidence rates, and modality-specific toxicity profiles. Results: RIBI represents a pathophysiological continuum. (a) Descriptive imaging patterns: In prospective proton therapy series, focal RICE occured in 15% of patients, typically at a median of 12 months, and often resolved spontaneously. (b) Modality comparison: Although proton therapy reduces integral brain dose versus photon therapy, elevated linear energy transfer (LET) at the distal Bragg peak may contribute to focal radiation-associated image changes (RAIC), particularly in the temporal lobes. (c) Risk stratification and diagnosis: Risk increased when &gt;1% of the healthy brain received &gt;57.6 Gy (Relative Biological Energy (RBE)) or when V67Gy exceeded 0.17 cc. Advanced MRI and amino acid positron emission tomography (PET) improved differentiation between radiation effects and tumor recurrence. Conclusions: Post-radiation imaging changes are common and often benign. Distinguishing RICE from progression requires multimodal imaging and adherence to specific dose constraints. Management should prioritize surveillance for asymptomatic lesions.<\/jats:p>","DOI":"10.3390\/diagnostics16081166","type":"journal-article","created":{"date-parts":[[2026,4,14]],"date-time":"2026-04-14T15:47:02Z","timestamp":1776181622000},"page":"1166","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["MRI and PET Alterations in Adult Skull Base Tumors: A Narrative Review of Proton Versus Photon Radiotherapy"],"prefix":"10.3390","volume":"16","author":[{"given":"Gokoulakrichenane","family":"Loganadane","sequence":"first","affiliation":[{"name":"Department of Radiation Oncology, Institut Curie, 75005 Paris, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7156-9750","authenticated-orcid":false,"given":"Valentin","family":"Calugaru","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Institut Curie, 75005 Paris, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dimitri","family":"Anzellini","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Sant\u2019Andrea Hospital, Sapienza University, 00189 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Benjamin","family":"Nicaise","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Institut Curie, 75005 Paris, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sarah","family":"Mezghani","sequence":"additional","affiliation":[{"name":"Department of Radiology, Institut Curie, 75005 Paris, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5106-6665","authenticated-orcid":false,"given":"Nam P.","family":"Nguyen","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Howard University, Washington, DC 20060, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brandi R.","family":"Page","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,14]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1752","DOI":"10.1212\/CON.0000000000001361","article-title":"Skull Base Tumors","volume":"29","author":"Forst","year":"2023","journal-title":"Continuum"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"e298","DOI":"10.1055\/s-0041-1729975","article-title":"Operative Anatomy of the Skull Base: 3D Exploration with a Highly Detailed Interactive Atlas","volume":"83","author":"Kockro","year":"2022","journal-title":"J. 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