Radiation-induced vasculopathy

Created 14/02/2022, last revision 26/12/2022

Patients after head and neck RT should be regularly monitored by ultrasound for early detection
of carotid steno-occlusive disease

  • radiation therapy (RT) is an important part of the treatment of primary and metastatic tumors
  • the brain, cranial nerves, spinal cord, and brain and heart vessels may be affected, among others
  • radiation-induced vasculopathy (angiopathy) is a heterogeneous and poorly defined complex of vessel injuries due to radiation
    • both small and large vessels can be impaired, resulting in extracranial carotid stenosis, intracranial stenosis, and other vascular anomalies (e.g., cavernous malformations, aneurysms, moya-moya syndrome, etc.)
    • not only brain vessels are affected, premature coronary artery disease (CAD) usually involves the ostium or proximal coronary arteries and may be due to endothelial injury with subsequent changes typical for atherosclerosis
    • the dose, duration, and tissue type during radiotherapy play important roles
  • vasculopathy carries an increased risk of cardiovascular complications in the decades following the initial treatment
    • occlusive vasculopathy is now being seen years after initial radiotherapy (2-25 y)  with an increased incidence because of improved oncological treatments and patient survival
    • increased recognition of radiation vasculopathy is critical to start early treatment strategies


Vascular injury

  • acute radiation damage leads to impaired HEB ⇒ vasogenic edema
  • the late vascular complications are caused by endothelium damage, leading to:
    • telangiectasia
    • aneurysm formation
    • microangiopathy
    • atherosclerosis of medium to large vessels
  • significant carotid vasculopathy (as a late complication of radiotherapy) occurs most often after radiotherapy in the ENT area (18-40%)

Damage to glia and white matter

  • oligodendrocytes are first to be affected, as neurons are relatively less sensitive to radiation
  • brain atrophy and extensive leukoencephalopathy can be seen on the MRI


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Diagnostic evaluation

Imaging findings of radiation vasculopathy show a predictable location and time course. The acute injury occurs within several weeks of treatment, early delayed injury within several weeks to months, and late injury months to years after the treatment

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  • antiplatelet therapy
    • in case of cancer-related thrombosis, LWHMs or DOACs are prescribed
  • vascular risk factors modification
    • statins
    • blood pressure monitoring and aggressive treatment of hypertension
    • no smoking
  • follow-up for detection of premature carotid artery stenosis and CAD
    • consider CEA or CAS  if significant stenosis is detected
    • vessel anatomy, surgical risk factors, and patient´s prognosis must be taken into account
    • both options share good short-term outcomes and similar perioperative complication rates; CEA offers more potentially durable vessel patency
    • CABG can be challenging given heavily calcified or friable internal mammary arteries
  • treatment of intracranial radiation-induced aneurysms by both open and endovascular methods has been described
CAS in patient with radiation-induced vasculopathy

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Radiation-induced vasculopathy