⚡ Stroke can complicate head and neck radiotherapy, manifesting as TIA or ischaemic stroke.
🩸 It particularly affects smaller penetrating vessels in the radiation field.

💡 Key point: Radiation-induced vasculopathy is a late complication, often presenting years after treatment. Always ask about previous radiotherapy in young patients with stroke.

Delayed Effects of Radiation

⏳ Occlusive vasculopathy is delayed, appearing years after therapy.
🧠 May mimic moyamoya disease with net-like collaterals and transdural anastomoses.
📈 Rising cancer survival rates mean more patients are living long enough to develop these vascular complications.

Tumours Requiring Radiotherapy

🗣️ Squamous cell carcinoma of the head and neck.
🧬 Lymphoma and 🩺 breast cancer (neck fields often included).
🧠 Pituitary tumours (adults), optic pathway gliomas (children).
🌏 Nasopharyngeal carcinoma → radiation field often involves both carotid arteries.

🩺 Clinical Features

⚠️ Ischaemic stroke or TIA.
🚶 Often lacunar-type episodes (penetrating vessel disease in radiation field).
🎧 Signs of carotid stenosis may also develop (bruit, amaurosis fugax, hemispheric TIA).

📝 Exam pearl: A history of radiotherapy is a red flag for stroke in younger patients without conventional risk factors.

🔎 Investigations

🩻 CTA: Identifies strictures, narrowing, and collateral vessels in radiation field.
🧲 MRI: Detects small infarcts in affected territories.
🩺 Carotid Duplex: Detects carotid narrowing/stenosis.

Differential Diagnosis

👴 Standard small vessel disease due to hypertension, diabetes, or age.
🧬 Moyamoya disease (can look very similar radiographically).
🦠 Vasculitis (rare but important to consider).

💊 Management

🏥 Standard stroke management (ABCs, risk factor control: BP, lipids, diabetes, smoking cessation).
🔧 Carotid endarterectomy is technically challenging due to scarred tissues from radiotherapy.
🧩 Stenting is often an alternative but carries higher restenosis risk.

🌟 Clinical takeaway: Always consider prior radiotherapy as a stroke risk factor. Manage aggressively like standard atherosclerotic disease, but anticipate surgical challenges.

References and Further Reading

Ischaemic Stroke and Transient Ischaemic Attack After Head and Neck Radiotherapy. Stroke. 2011;42:2410-2418.

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Cerebral Radiation Vasculopathy

Introduction