Radiation-induced vasculopathy

Created 14/02/2022, last revision 04/04/2023

Patients after head and neck radiotherapy should be regularly monitored with ultrasound to detect 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
  • radiation-induced vasculopathy (angiopathy) is a heterogeneous and poorly defined complex of vascular injuries caused by radiation
    • both small and large vessels can be affected, resulting in extracranial carotid stenosis, intracranial stenosis, and other vascular anomalies (e.g., cavernous malformations, aneurysms, moya-moya syndrome, etc.)
    • not only cerebral arteries 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
    • total dose, duration and type of tissue being exposed play an important role
  • 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 due to improved oncological treatment 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 endothelial 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 ENT radiotherapy (18-40%)

Glial and white matter injury

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


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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
  • a follow-up to detect premature carotid artery stenosis and CAD
    • consider CEA or CAS  if significant stenosis is detected
    • vascular anatomy, surgical risk factors, and the patient´s prognosis must be taken into account
    • both options share good short-term outcomes and similar perioperative complication rates; CEA probably offers more durable vessel patency
    • CABG can be challenging in the presence of heavily calcified or friable internal mammary arteries
  • both open and endovascular treatment of intracranial radiation-induced aneurysms has been described
CAS in patient with radiation-induced vasculopathy

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Radiation-induced vasculopathy